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ASEPTIC 
SURGICAL TECHNIQUE 



With Especial Reference to Gyncecological Operations, 

together with Notes on the Technique Employed 

in Certain Supplementary Procedures 



BY 

HUNTER ROBB, M.D. 

M 

FORMERLY PROFESSOR OF GYNECOLOGY, WESTERN RESERVE UNIVERSITY AND 

GYN..ECOLOGIST-IN- CHIEF TO THE LAKESIDE HOSPITAL, CLEVELAND, 

OHIO; FELLOW OF THE AMERICAN GYNAECOLOGICAL SOCIETY 

AND OF THE AMERICAN COLLEGE OF SURGEONS, ETC. 



44 TEXT FIGURES AND 24 PLATES 



FIFTH EDITION, REVISED 



PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



v9 \fc 



Copyright, 1894, by J. B. Lippincott Company 



Copyright, 1901, by J. B. Lippincott Company 



Copyright, 1902, by Hunter Robb 



Copyright, 1906, by Hunter Robb 



Copyright, 1916, by Hunteb Robb 




ELECTROTYPED AND PRINTED B*S. B. LIPPINCOTT COMPANY, PHILADELPHIA, U.S. A 



MflR -2 1916 



5>CUJ20971 



TO 
HOWARD A. KELLY 

PROFESSOR OF GYNECOLOGY, JOHNS HOPKINS 
UNIVERSITY 



PREFACE TO THE FIFTH EDITION, 
REVISED. 



In the present edition a number of new illustra- 
tions will be found. Certain necessary changes have 
been made in the text, and a chapter on endome- 
tritis has been added. 

Hunter Eobb. 
Cleveland, December, 1915. 



PREFACE TO THE FIRST EDITION. 



In preparing this book I have availed myself of the 
writings of my predecessors in this field, and have 
gathered much from their work , especially from that 
of Schimmelbusch, Terrillon, and Sanger. The tech- 
nique recommended is in the main that practised in 
the gynaecological and surgical departments of the 
Johns Hopkins Hospital. 

I have to express my sincere thanks to Professor 
Welch, to Dr. L. F. Barker, and others for kind sug- 
gestions, and to Dr. F. R. Smith for the revision of 

the manuscript. 
Baltimore, June, 1894. 



vn 



CONTENTS. 



CHAPTEE I. 

PAGE 

Importance to the surgeon of a bacteriological training — 
Sepsis and wound-infection — Micro-organisms concerned 
—Asepsis — Antisepsis 9-32 

CHAPTER II. 

Principles of sterilization — Dry and moist heat — Fractional 

sterilization — Chemical disinfection 33-45 

CHAPTER III. 

Practical application of the principles of sterilization — Oper- 
ating suits — Preparation of the surgeon and his assist- 
ants 46-58 

CHA-PTER IY. 

The preparation of patients for operations, major and minor 

— Means employed to obtain an aseptic field 59-65 

CHAPTER V. 

Gynaecological instruments — Methods of sterilization — In- 
strument trays — Care of the instruments after operations 66-90 

CHAPTER VI. 

Aseptic sutures, ligatures, and carriers — Suture materials — 

Sterilization and preservation of the various kinds . . . 91-103 

ix 



X CONTENTS. 

CHAPTEK VII. 

PAGE 

Sterilized dressings — Cotton — Gauzes — Bandages — Tampons 

— Sponges 104-114 

CHAPTEK VIII. 

Aseptic drainage — Glass arid rubber drainage-tubes — Gauze 
drains — Care of rubber materials — Kubber dam — Eubber 
tubing — Kubber gloves and armlets 115-127 

CHAPTEK IX. 

Fluids for irrigation — Plain sterile water — Antiseptic fluids 
for irrigation — Sterile physiological salt solution — Anti- 
septic powders — Iodoformized oil — Bichloride celloidin — 
Iodoformized celloidin — Silver foil — Gutta-percha .... 128-139 

CHAPTER X. 

On certain procedures sometimes necessary before and after 
operations, which must be conducted aseptically — Hypo- 
dermic injections — Exploratory punctures — Catheteriza- 
tion — Bladder-washing — Ureteral catheterization .... 140-147 

CHAPTER XL 

The gynaecological operating-room — Operating-table — Instru- 
ment-cases and other furnishings ._ 148-159 

CHAPTER XII. 

The organization of operations — The maintenance of an 

aseptic technique during operations 160-177 

CHAPTER XIII. 

Post-operative care — Position in bed — Diet — Vomiting — 
Rectal feeding — Shock — Pain and restlessness — Con- 
stipation — Catheterization — Convalescence — Removal of 
stitches — Dressings subsequent to operations — Hemor- 
rhage — Intestinal obstruction — Infection 178-195 



CONTENTS. XI 



CHAPTER XIV. 



PAGK 



Operations in the country, in private houses, or in other 
places where the technique must necessarily be more or 
less imperfect — The armamentarium — An improvised 
operating-room — Modifications in technique 196-208 

CHAPTER XV. 

Anaesthesia as an aid to diagnosis : its importance in general 
surgery and gynaecology — Preparation of the patient — 
Position — Methods of examination — Rectal palpation . . 209-217 

CHAPTER XVI. 

Bacteriological and clinical examinations in surgery and 

gynaecology 218-227 

CHAPTER XVII. 

The examination of the interior of the female bladder, and 

the catheterization of the ureters 228-237 

CHAPTER XVIII. 
Pathological examinations . . . . , 238-252 

CHAPTER XIX. 

Endometritis : Nomenclature — Histology — Changes in endo- 
metrium during menstruation and in old age — The De- 
cidua — Infections — Gonorrhoea — Septic endometritis — 
Trophic endometritis , 252-279 



LIST OF ILLUSTRATIONS. 



PLATES. 

PAGE 

Plate I. — Figures of eight different bacteria . . . Frontispiece 

Plate II. — Sterilization of the hands with permanganate of 

potassium 56 

Plate III. — Fig. 1, Long dressing-forceps ; Fig. 2, Drainage- 
tube forceps with Kelly's lock 71 

Plate IV. — Fig. 1, Haemostatic forceps ; Fig. 2, Bullet-forceps . 71 

Plate V. — Fig. 1, Rat-tooth forceps; Fig. 2, Curved needles; 

Fig. 3, Transfixion needles 71 

Plate VI. — Fig. 1, Needle-holder; Fig. 2, Vaginal packer; 

Fig. 3, Retractor ; Fig. 4, Scalpels 72 

Plate VII. — Fig. 1, Scissors; Fig. 2, Uterine sound; Fig. 3, 

Sims's speculum 74 

Plate VIII. — Fig. 1, Trivalve speculum; Fig. 2, Sponge- 
holder ; Fig. 3, Corrugated tenaculum 75 

Plate IX.— Fig. 1, Trocar; Fig. 2, Nelaton's forceps .... 76 

Plate X. — Fig. 1, Simon's speculum ; Fig. 2, Curettes .... 78 

Plate XI. — Fig. 1, Modified Goodell-Ellinger dilator, smallest 

size; Fig. 2, Hegar's dilator; Fig. 3, Shot-compressor ... 78 

Plate XII. — Fig. 1, Two-way catheter; Fig. 2, Chloroform- 
bottle ; Fig 3, Chloroform-inhaler ; Fig. 4, Tenacula ... 78 

Plate XIII. — Fig. 1, Glass dishes; Fig 2, Sterilized towels in 
three-per-cent. carbolic solution ; Fig. 3, Sterile cotton in 
glass jar; Fig. 4, Sponges in three-per-cent. carbolic solu- 
tion ; Fig. 5, Sterilized tampons in glass jar; Fig. 6, Steril- 
ized gauze in glass jar ; Fig. 7, Ligatures in glass jar ; Fig. 
8, Gauze drains 86 

Plate XIV.— Fig. 1, Flasks for sterile salt solution; Fig. 2, 

Movable irrigator 132 

xiii 



XIV LIST OF ILLUSTRATIONS. 

PAGE 

Plate XV.=Gynaecological operating-room, Lakeside Hospital, 

Cleveland, Ohio 154 

Plate XVI. — Instrument cases 154 

Plate XYII. — Fig. 1, Haemostatic forceps strung on steel ring ; 
Fig. 2, Floating glass label ; Fig. 3, Glass basins ; Fig. 4, 
Cotton pledgets in glass bottles; Fig. 5, Agate-ware vessel, 

with top protected with gauze 154 

Plate XVIII. — Field of operation and the neighboring parts 

protected by gauze diaphragm, towels, and stockings .... 176 

Plate XIX. — Examination under sheet 214 

Plate XX. — Patient in knee-chest position, cystoscope about 

to be inserted (after Kelly) 232 

Plate XXL — Fig. 1, Normal mucous membrane of the uterus 
(after Zweifel) ; Fig. 2, Chronic interstitial endometritis 

(after Zweifel) 242 

Plate XXII. — Fig. 1, A normal cervical gland; Fig. 2, 

Normal senile endometrium 254 

Plate XXIII. — Fig. 1, Interstitial exudative endometritis ; 

Fig. 2, Hypertrophy of uterine glands 260 

Plate XXIV. — Tuberculous endometritis 270 

FIGURES. 

Fig. 1. — Hot-air sterilizer 35 

Fig. 2. — Hot and cold water tanks 36 

Fig. 3. — Steam sterilizer 37 

Fig. 4. — Steam sterilizer (in section) 38 

Fig. 6. — Suits worn by operator and nurse 49 

Fig. 6. — Spigot attachment 55 

Fig. 7. — Robb's aseptic razor, with case 62 

Fig. 8 — Instruments in metal box 81 

Fig. 9. — Boiler for soda solution 85 

Fig. 10. — Instrument sterilizer 86 

Figs. 11, 12. — Basins for instruments 88 

Fig. 13. — Aseptic ligature tray 89 

Fig. 14. — Needle armed with carrier 92 

Fig. 15. — Glass reels for ligatures 94 

Figs. 16, 17. — Ignition test-tubes with ligatures on reels .... 94 

Fig. 18. — Sterilized catgut in sealed glass tubes 96 



LIST OF ILLUSTRATIONS. XV 

PAGE 

Fig. 18a. — Tube of sterilized catgut 103 

Fig. 19. — Modified Scultetus bandage Ill 

Fig. 20. — Sponge made of cotton and gauze 112 

Fig. 21.— Thermometer jar 132 

Fig. 22 — Glass douche-nozzle 134 

Fig. 23. — Aseptic powder flask 136 

Fig. 24. — Glass catheter 145 

Fig. 25. — Glass catheters in one to twenty carbolic acid solution . 146 

Fig. 26. — Movable incandescent lamp 150 

Fig. 27. — Operating-table : Robb's electric light attachment . . 151 

Fig. 28 — Halsted's semicircular table for instruments 154 

Fig. 29. — Rubber ovariotomy pad 164 

Fig. 30. — Sponging out cul-de-sac 171 

Fig. 31. — Removal of abdominal sutures 175 

Figs. 32, 33.— Robb's leg-holder 176 

Fig. 34. — Hot-water can 179 

Fig. 35. — Abdominal bandage 191 

Fig. 36. — Canton-flannel sheet for instruments 198 

Fig. 37. — Instruments wrapped in canton-flannel sheet .... 199 

Fig. 38.— Double urethral dilator 230 

Fig. 39. — Speculum and obturator 230 

Fig. 40. — Delicate mouse- toothed forceps 231 

Fig. 41. — Ureteral catheters, without handles, for direct catheter- 
ization through speculum 231 

Fig. 42. — Section through a blood-clot from the uterus after abor- 
tion, showing transverse and longitudinal sections of chori- 
onic villi (after Orth ) 246 

Fig. 43. — Adeno-carcinoma of the uterine body (after Orth) . . 247 

Fig. 44. — Epithelioma of the cervix (after Orth) 248 



INTRODUCTION. 



I do not think any student of the history of medi- 
cine will for a moment dispute the assertion that the 
importance of the changes wrought in our surgical 
technique within the past ten years is unparalleled 
by that of any previous century of medical or surgical 
progress. 

Those changes which were inaugurated with the 
recognition of the infectious nature of wound-inflam- 
mation were distinctly revolutionary, while the changes 
of the more immediate past have been evolutionary 
in character ; accepting the germ theory as the work- 
ing principle, the object of our toilers in the field of 
original research has been the elaboration of a method 
by which these enemies to successful surgery might 
be eliminated from the field. 

This direct application of the principle in the prac- 
tical field has been but recently satisfactorily estab- 
lished after numerous experiments conducted in the 
laboratory upon animals and tested upon patients in 
the operating-room. 

Only by a slow process, considering the vast number 
of experiments conducted in all our hospitals, have 
we grown out of an antisepsis of toxic drugs into the 



XVll 



xviii INTRODUCTION. 

simpler antisepsis of moist heat and saponaceous de- 
tergents. 

Throughout these momentous changes in the surgi- 
cal arena Dr. Robb has been a faithful observer, and 
not an observer only, but frequently an active par- 
ticipant, assisting the evolution of the new idea, con- 
stantly following the work of others, repeating their 
experiments, and performing experiments of his own, 
notably in connection with my own work, which have 
been valuable in aiding the progress of the technique 
step by step until it has attained its present position. 
It was Dr. Robb's work in relation to disinfection by 
permanganate of potassium and oxalic acid which first 
established on a scientific basis the reliability of this 
method when applied to the hands. His studies 
regarding the infection of the drainage-tube tract are 
also notable. 

It is therefore on account of his labors in the bac- 
teriological laboratory, while keeping himself at the 
same time constantly in close relation to the eminently 
practical surgical questions of the day during a decade 
of unprecedented progress, that Dr. Robb is eminently 
qualified to speak and command our interested atten- 
tion in relation to the subjects treated in the book 
before us. 

Howard A. Kelly. 



ASEPTIC SURGICAL TECHNIQUE. 



CHAPTER I. 

IMPORTANCE TO THE SURGEON OF A BACTERIOLOGICAL TRAIN- 
ING — SEPSIS AND WOUND-INFECTION — MICRO-ORGANISMS CON- 
CERNED — ASEPSIS — ANTISEPSIS. 

The number of those who do not believe it necessary 
to observe stringent precautions in operative surgery 
or who are content to confine themselves to methods 
which have been proved to be faulty is now, fortu- 
nately, very small, and is diminishing every day, so 
that we may safely say that every prominent surgeon 
is now working on practically the same lines, being 
anxious to discover and to carry out any measure 
which promises to aid the speedy healing of the 
wounds which he makes and to obviate the dangers 
of infection. 

Among the brilliant results to be obtained from the 
study of bacteriology, none seems at the present time 
more important than the establishment on a scientific 
basis of a thorough technique for surgical operations. 

It will obviously be impossible for a surgeon to have 
any fixed rules by which he may be guided unless he 
has first obtained a true conception of the meaning of 

9 



10 ASEPTIC SURGICAL TECHNIQUE. 

the terms sepsis, asepsis, and antisepsis, and is deter- 
mined at all costs to apply his knowledge practically 
to his every-day work. While the majority of our 
operators of to-day may theoretically appreciate the 
dangers of wound-infection, and have read or heard 
of the various means that are to be taken to prevent 
it, there are few comparatively who are consistent in 
the technique which they employ. 

It is by no means unusual to hear a surgeon remark 
that he has performed an " aseptic" operation, or that 
he always operates " under strictly aseptic precau- 
tions," when his technique, as actually observed by 
one trained in bacteriology, is found to be wofully 
defective. 

The practical scientific application of an aseptic and 
antiseptic technique can be thoroughly carried out 
only by observing every, even the most minute, detail, 
the utility of which has been proved by bacteriological 
experiment. In order to become familiar with these 
details, and to be able to appreciate them fully, the 
surgeon should have had at least an elementary train- 
ing in bacteriology. If he has not had this training, 
— and, unfortunately, it has not as yet been possible 
to secure it at the majority of medical schools, — 
he must accept and carry out in his work princi- 
ples which have been laid down by those who have 
had the opportunity of submitting their methods to 
the test of bacteriological criticism. Any one who 
has been trained in a bacteriological laboratory will 
have exalted ideas of surgical cleanliness, and cannot 



INCONSISTENCIES IN TECHNIQUE. H 

fail to see the many inconsistencies that occur dur- 
ing the majority of operations. While these incon- 
sistencies may to many appear trifling, in reality they 
are only too often responsible for the introduction 
of infectious material into the wound. One would 
think that an operator, after taking every precaution 
to render his hands surgically clean, would avoid 
bringing them in contact subsequently with objects 
which have not been previously sterilized, and yet it 
is by no means uncommon to see those who are re- 
garded as " careful men" touching with their hands 
the face or hair, or permitting them to come in contact 
with some non-sterile article — such, for example, as a 
blanket which protects the patient — just prior to or 
during an operation, and proceeding with their work 
without thoroughly cleansing them again. If such 
errors in technique be committed by the operator him- 
self, he can scarcely expect his assistants and nurses 
to exercise proper precautions. 

I remember seeing a surgeon leave the operating- 
table, while performing an abdominal section, to pick 
up an unsterilized instrument which he wished to 
bend at a certain angle and employ in order better to 
expose the parts. In doing this he used as a support 
a table and a chair that happened to be near at hand, 
but which were unsterilized. After having bent the 
instrument to the desired shape, the surgeon proceeded 
to employ it immediately without making any attempt 
to sterilize either it or his hands. I have also seen a 
nurse, who was assisting with the handling of the 



12 ASEPTIC SURGICAL TECHNIQUE. 

sponges at an abdominal section, take her hand- 
kerchief from her pocket, wipe her nose with it, and 
at once continue with her duty of passing the sponges 
to the assistant surgeon. On another occasion I saw 
a surgeon open an abdomen, and after himself exam- 
ining the structures of the pelvic cavity, invite two 
professional brethren who were looking on to do the 
same ; and they were actually permitted to introduce 
their hands into the wound after having simply washed 
them for a minute or two with soap and water in a 
soiled basin. At another time an assistant, after draw- 
ing a ligature between his teeth, proceeded to thread 
the needle with it for the surgeon to use in the abdomi- 
nal wound. Some surgeons have even been guilty of 
holding the scalpel between the teeth in the course 
of an operation. 

It would hardly be necessary to mention such glaring 
instances of faulty technique were it not for the fact 
that errors as bad as these have been observed in men 
who are considered leaders, and to whose lot it falls 
to instruct others in surgery. While the surgical 
judgment and skill of such men may be undoubted, 
the technique which they employ is dangerous and per- 
nicious. Even after we have become thoroughly im- 
bued with the importance of aseptic work, and have 
made the most careful preparations before our oper- 
ations, the technique will never be perfect unless we 
have schooled ourselves to provide against the unfore- 
seen dangers which are constantly turning up in the 
operating-room. Every operator of experience, no 



INFECTION. 13 

matter how conscientious and careful, has met with 
fatal cases in his practice due to faulty methods, and 
has had inflammation with pus-formation at or near 
the site of the wound which he has made. 

He who is thoroughly conversant with the condi- 
tions which underlie suppuration in wounds and septic 
processes generally, knows only too well how many 
are the loop-holes for infection, and to him it seems 
really remarkable that such cases do not occur more 
frequently. It is not improbable, especially in condi- 
tions of lowered resistance where the cells and tissue 
fluids of the body do not exercise their normal germi- 
cidal power, or do so only in a feeble way, that infec- 
tion may occur, even though all possible precautions 
have been taken by the surgeon and his assistants. 
Experiments have shown that no method has yet been 
discovered by which the skin can be rendered abso- 
lutely sterile, and that the cutaneous glands contain, 
even after the most careful disinfection of the surface, 
micro-organisms which in a proper " soil" are capa- 
ble of giving rise to inflammation and suppuration. 
Though it may be true, as has been contended by 
good men, that every wound made by the surgeon 
contains micro-organisms, we may assume that under 
ordinary circumstances the resisting powers of the 
patient will be suflicient to prevent their growth and 
development. Experience, however, has taught us 
that there are several kinds of bacteria which under 
certain conditions possess such virulence, that when 
introduced into the tissues even of a perfectly healthy 



14 ASEPTIC SURGICAL TECHNIQUE. 

individual they are capable of setting up violent local 
or general infections. And it is only right that 
every surgeon shall do everything in his power to 
prevent the ingress of such bacteria. While admit- 
ting that an infection following an operation must, 
with our present knowledge, be sometimes attributed 
to a lowered systemic resistance and to no fault on 
the part of the operator or his assistants, it must be 
understood that this is a very rare occurrence, and 
that in nearly every septic case a rigid analysis of 
the technique employed will bring to light some sin 
of omission or of commission to account for it. I 
believe that a perfect technique can ultimately be 
attained by submitting every step to the test of bac- 
teriological examination, and the surgeon who works 
on these lines will, cceteris paribus,, undoubtedly obtain 
the best results in his own operations, and, what is 
perhaps just as important, he will be able by his teach- 
ing and example to inculcate in others principles by 
the adoption of which much loss of life may be pre- 
vented. 

That some surgeons do not seem to pay much at- 
tention to a careful technique and yet obtain good 
results is no sound argument against the carrying 
out of thoroughly scientific procedures. As a matter 
of fact, a careful investigation of their results and 
those of their followers compared with those of 
aseptic surgeons and their students will, if a suffi- 
cient number of parallel cases be taken, certainly 
show the inferiority of the older methods. Statistics 



SEPSIS. 15 

showing uniformly good results from operations in 
which no precautions were taken will usually be found 
to be based on too limited a number of cases to be of 
much value. 

The term sepsis, or septic infection, includes nearly 
all of the surgical infections, general or local, result- 
ing from bacterial invasion. The symptoms are due, 
as a rule, not so much to the direct effect of the bac- 
teria themselves as to the action of their chemical 
products. When the bacteria have gained entrance 
into the general circulation and have multiplied there 
(and several varieties are capable of doing this), we 
have a general blood-infection which often proves 
fatal. With or without extensive multiplication of 
the micro-organisms in the blood, the system may be 
overwhelmed with the bacterial poisons. This condi- 
tion is called acute septicemia. Localization of pyo- 
genic bacteria in the organs, especially when they 
have been transported there by infectious emboli, 
gives rise to multiple abscess-formation. This condi- 
tion is called pyemia. These terms are, of course, 
only relative, and it is customary to speak of infec- 
tions in which the two conditions are combined as 
cases of septico-pycemia. 

Under the head of local infections we at the present 
day group together all those so-called " accidents" 
which befall wounds : suppuration, traumatic fever, 
hospital gangrene, wound- diphtheria, and erysipelas. 
All of these, though met with much less often than 



16 ASEPTIC SURGICAL TECHNIQUE. 

of old, are still occasionally seen. The rarity of their 
occurrence is to be attributed to the improvement in 
operative technique and the less frequent infection of 
wounds. The phenomena appearing after the absorp- 
tion into the general circulation of the products re- 
sulting from the local growth of micro-organisms, 
especially putrefactive forms, have been included 
under the term saprwmia or toxcemia, but it is not 
possible to make any sharp distinction between 
sapraemia and septicaemia. The importance of recog- 
nizing clearly the distinction between a purely local 
infection and a general infection of the blood and 
organs with bacteria will be easily understood. In 
the former case the symptoms produced are in direct 
proportion to the amount of poison absorbed, and if 
this absorption has not been too great, they will all 
disappear with the subsidence of the local infection. 
In a general infection, on the other hand, fresh poi- 
son is being constantly produced by the bacteria dis- 
tributed everywhere through the body, so that local 
therapeutic measures can then be of no avail. 

General septicaemia, or pyaemia, may be set up by 
almost any of the micro-organisms which have pyo- 
genic properties, — i.e., which are capable of giving rise 
to local suppuration. The organisms most frequently 
met with in surgical experience are : the staphylococcus 
pyogenes aureus, the streptococcus pyogenes, and the bac- 
terium coli commune. Less frequently we have to deal 
with the staphylococcus epidermidis albus, the staphylococ- 
cus pyogenes albus, the staphylococcus pyogenes citreus, the 



PATHOGENIC ORGANISMS. 17 

gonococcus of Neisser, the bacillus of green pus (bacillus 
pyocyaneus), the bacillus aerogenes capsulatus, and the 
micrococcus lanceolatus (diplococcus pneumoniae). 

It will be well, perhaps, to describe briefly the prin- 
cipal micro-organisms which concern us in our work, 
and especially the pyogenic bacteria. The forms chiefly 
concerned in suppurative processes are cocci. Of 
these the staphylococcus, of which several varieties 
have been isolated, distinguished by differences both in 
their chromogenic properties and in their pathogenic 
power, has been found more frequently than any other 
associated with acute phlegmons. 

The staphylococcus pyogenes aureus (Ogston, Rosen- 
bach, et al.), or golden staphylococcus, is the most im- 
portant form for the surgeon, and is more common 
than any other. It is widely distributed in nature, its 
presence having been repeatedly demonstrated upon 
the skin of healthy persons, in the secretions of the 
mouth, beneath the finger-nails, in the air, especially 
in that of hospital wards, in the water, and elsewhere. 

It can thus be easily understood how readily it can 
come in contact with the field of operation. The 
cocci grow in grape-like bunches, but in the tissues 
are also seen in pairs or in groups of four. Plate I., 
Fig. 1. They stain well in the ordinary aniline dyes, 
and also by the method of Gram. 

The staphylococcus aureus grows well on all the 
culture media of the laboratory, and forms, especially 
when allowed to grow slowly with free access of air, 

large golden-yellow masses. 

2 



18 ASEPTIC SURGICAL TECHNIQUE. 

Its pathogenic power is variable, some varieties 
being much more virulent than others. Its pyogenic 
properties for human beings have been clearly proved 
by the experiments * of Garre, who rubbed into the 
uninjured skin of his left forearm a pure culture of 
this organism. Four days afterwards a large carbuncle, 
which was surrounded by isolated furuncles, appeared 
at the site of the inoculation. The inflammation thus 
established ran the usual course, and it was only after 
several weeks that the skin healed over completely. 
Seventeen scars remained as a lasting proof of the 
success of the experiment. 

When cultures of this coccus are injected into the 
vein of a rabbit's ear, the animal dies after a certain 
period of time (which varies according to the viru- 
lence of the particular culture used), with symptoms 
of acute septicaemia, and at the autopsy necroses or 
small abscesses are found in the various organs. 

In human beings this organism has been isolated 
from suppurating foci of all kinds and in all situations. 
It is the most frequent cause of superficial and deep 
abscesses as well as of acute osteomyelitis, and has 
often been recognized as the infectious agent in acute 
ulcerative endocarditis and general septicaemia follow- 
ing operations or childbirth. 

The staphylococcus pyogenes albus, while resembling 
the aureus in form, can be distinguished from it in 
that it grows as a white coating on the culture media, 
and moreover is possessed of less virulence. It has in 
some instances been found as the only micro-organism 



PATHOGENIC ORGANISMS. 19 

present in acute abscesses, but, as a rule, it is asso- 
ciated with other pyogenic cocci, most frequently 
with the staphylococcus pyogenes aureus. 

The staphylococcus epidermidis albus is so called be- 
cause it is almost always present, even under nor- 
mal conditions, in the human skin. According to 
Welch, it is often found in parts of the epidermis 
deeper than can be reached by any known method 
of cutaneous disinfection without injuring the patient, 
and he therefore regards it as a nearly constant in- 
habitant of the epidermis. This coccus resembles 
very closely the staphylococcus pyogenes albus, and 
is distinguished from it only by minor cultural differ- 
ences and by its lower virulence. It has frequently 
been found in wounds, the healing of which did not 
appear to be at all delayed; but experiments have 
proved that it sometimes causes suppuration along 
the line of the stitches and in the track of a drainage- 
tube. In a series of forty-five laparotomy wounds 
examined by Dr. Ghriskey and myself, where every 
aseptic precaution had been observed, bacteria were 
found in thirty-one, or sixty-nine per cent, of the 
whole ; in only fourteen were the results of the cul- 
tures negative. In nineteen cases we found the 
staphylococcus epidermidis albus, in five the staphylo- 
coccus pyogenes aureus, in six the bacterium coli 
commune, and in three only the streptococcus pyo- 
genes. 

Cultures made also in a large number of cases from 
the hands and from the surface of the abdomen showed 



20 ASEPTIC SURGICAL TECHNIQUE. 

that, even after the application of the different methods 
recommended for surface disinfection, the staphylo- 
coccus epidermidis albus still remained, and that, too, 
in such a condition as to be capable of developing on 
the ordinary media. 

The staphylococcus pyogenes citreus (Passet) is char- 
acterized by its lemon-yellow growth on agar-agar. 
It has been found alone in abscesses, and must be 
looked upon as a pyogenic micro-organism, although 
it occurs much more rarely than any of the other 
forms. 

The streptococcus pyogenes grows in chain8 consisting 
of from four to ten or more cocci, each individual 
coccus being somewhat larger than those seen in cul- 
tures of the staphylococcus. Plate I., Fig. 2. This 
organism stains well by all the ordinary methods. 
In culture media it grows very differently from the 
staphylococcus, forming, as a rule, minute pin-point 
colonies. The streptococcus is one of the most im- 
portant micro-organisms with which the surgeon has 
to deal. It has long been known that erysipelatous 
inflammations are due to the so-called streptococcus 
erysipelatosus ; it is doubtful, however, whether this 
coccus can be distinguished from the ordinary strepto- 
coccus pyogenes. In fact, the differentiation of strep- 
tococci into distinct species or varieties has thus far 
met with little success. The streptococcus is found 
sometimes in acute abscesses, but not so frequently 
as the staphylococcus pyogenes aureus, with which 
it is often associated in acute suppurative processes. 



PATHOGENIC ORGANISMS. 21 

External inflammations due to the streptococcus are 
characterized especially by their spreading character 
and erysipelatous redness. The streptococcus pyo- 
genes is one of the most frequent causes of post-opera- 
tive peritonitis. It has further been proved to be the 
etiological factor in many cases of ulcerative endo- 
carditis as well as of acute septicaemia in human 
beings, and it is a well-known fact that the pseudo- 
membranous anginas complicating scarlet fever and 
measles are, as a rule, due to this organism. It has 
been found in some forms of acute broncho-pneu- 
monia, sometimes in acute pleurisy and empyema, 
and occasionally in acute osteomyelitis. Compara- 
tively recent researches have shown an interesting 
relation to exist between the streptococcus pyogenes 
and the different forms of puerperal infection. Doder- 
lein has shown that in the pathological secretions from 
the vagina, immense numbers of organisms, and gen- 
erally streptococci, are present. His work was based 
upon the study of the vaginal secretions from nearly 
two hundred women, about one-half of which were 
found to be abnormal ; in ten per cent, of the patho- 
logical secretions he was able to demonstrate the 
presence of the streptococcus pyogenes ; inoculation 
experiments proved that in at least fifty per cent, of 
these the organism was pathogenic for animals. 

It is not difficult, then, to understand how after 
labor, when the parts are wounded, organisms can 
enter the circulation and give rise to a general in- 
fection, the infectious agent being not infrequently 



22 ASEPTIC SURGICAL TECHNIQUE. 

the streptococcus pyogenes. Clivio and Monti have 
demonstrated the presence of streptococci in live cases 
of puerperal inflammation of the peritoneum. Czer- 
niewski found the same organism in the lochia of 
thirty-three out of eighty-one women suffering from 
puerperal fever, while in those of fifty-seven healthy 
women he was able to find it only once. In ten fatal 
cases he demonstrated its presence in the organs of 
the body after death. Such observations as these, and 
many more might be cited, are sufficient to impress 
upon us the importance of preventing the access of 
the streptococcus to open wounds. The organism is 
of very wide distribution, and it is only strange that 
more patients in surgical and obstetrical practice do 
not become infected by it. It may be that in many 
cases, having led a saprophytic existence, it has lost 
some of its virulence, and is not capable of setting 
up pathological processes unless it happens to enter 
a soil particularly suited for its development. Any 
one who has examined a drop of the fluid exudate 
from the abdominal cavity in a case of streptococcus 
peritonitis, and has seen the myriads of cocci present 
in a single microscopic field, will appreciate somewhat 
the developmental power of this organism. 

From what has been said, the danger of going from 
a case of erysipelas or of streptococcus phlegmon to 
a surgical operation or an obstetrical case will be 
sufficiently evident. Even with every antiseptic pre- 
caution more or less danger will be incurred, and 
one should never take the risk unless it is absolutely 



PATHOGENIC ORGANISMS. 23 

unavoidable. To go to such a case without thorough 
disinfection would be criminal. 

The micrococcus gonorrhoeae, or gonococcus, was dis- 
covered by Neisser in 1879. It is found in the gonor- 
rheal discharge and in the secretions from the eyes in 
cases of gonorrheal ophthalmia. According to some 
it is always present in the joints in gonorrheal rheu- 
matism, and it has been isolated from the muscular 
structures of the heart in cases of myocarditis following 
gonorrhea. It is usually to be seen lying within the 
pus-cells or attached to the surface of the epithelial 
cells. (Plate L, Fig. 3.) Its specific character has been 
proved by inoculation into man. It is extremely diffi- 
cult to grow outside of the body and will not develop 
at all on the ordinary culture media. A mixture of 
human blood-serum and agar-agar, or hydrocele-agar, 
gives excellent results. 

Yery considerable pathogenic importance has been 
attributed to this organism, and many gynecologists 
are ready to assert that nearly all inflammations of 
the tubes and ovaries in women are due to its agency. 
That it does play an important part in the etiology 
of these affections there can be but little doubt, but 
whether such an extreme opinion is justifiable remains 
still uncertain. The clinical history of the patient is 
occasionally of some assistance, but in the vast ma- 
jority of cases it is difficult to determine positively 
whether a pelvic abscess has or has not been preceded 
by an attack of gonorrhea. 

The micrococcus lanceolatus is also known as the 



24 ASEPTIC SURGICAL TECHNIQUE. 

diplococcus pneumonia and as the pneumococcus. It was 
discovered by Sternberg, and also independently by 
Pasteur. It has been studied thoroughly by Fraenkel, 
Weichselbaum, Welch, and others. 

It is an oval or lancet-shaped encapsulated diplo- 
coccus which often grows out into short chains, and 
on that account it was called by Gamaleia the strep- 
tococcus lanceolatus. Plate I., Fig. 4. It is present 
normally, either with or without virulence, in the 
saliva of nearly all human beings, and is the cause of 
the acute septicaemia (sputum septicaemia) which fre- 
quently results in rabbits from the inoculation into 
them of small quantities of human sputum. It is the 
causative factor in acute lobar pneumonia and also in 
many cases of acute broncho-pneumonia, and has been 
recognized as having given rise to many of the acute 
inflammations of the serous membranes of the body, 
— pleuritis, pericarditis, peritonitis, endocarditis, and 
meningitis. It is now known to be a definite pus- 
producer, and has been found more than once in acute 
abscesses, in empyema, in suppurative otitis media, 
in quinsy, and in suppurative polyarthritis. It is a 
rapidly-growing micro-organism, but is rather difficult 
to cultivate outside the body; it easily succumbs 
under adverse circumstances, and is extremely vari- 
able in its virulence. 

The bacillus coli communis, or bacterium coli commune, 
is constantly present in the faeces of man and of the 
higher animals. It is a bacillus about one and four- 
tenths micro-millimetres in thickness and two or three 



PATHOGENIC ORGANISMS. 25 

micro-millimetres in length. Plate L, Fig. 5. It is 
pathogenic for mice, rabbits, and guinea-pigs, and re- 
cently has been proved to be of some importance as 
an etiological factor in many of the inflammatory 
processes which occur in human beings. It appears to 
be the cause more often than any other organism of 
acute suppurative peritonitis, especially where there 
has been any communication between the lumen of the 
gastro-intestinal canal and the peritoneal cavity.* It 
has also been found in localized abscesses, in suppu- 
rative infections of the liver and gall-bladder, in acute 
hemorrhagic pancreatitis, in cystitis, in pyelitis, and in 
other conditions. It is interesting to note that in the 
infections due to this organism and to the micrococcus 
lanceolatus we have to deal with pathological lesions 
resulting from the action of bacteria which we nor- 
mally carry about with us in the exposed cavities of 
our bodies. 

The bacillus pyocyaneus was first isolated in pure cul- 
tures by Gessard, in 1882, from pus having a green or 

* In an article dealing with micro-organisms concerned in perfora- 
tion-peritonitis, Barbacci has endeavored to show that the bacillus 
coli communis, while always present in the exudate, is not the exciter 
of the inflammation. He believes that other bacteria, which do not 
grow from cultures made at the autopsies, but which can be observed 
in cover-slip preparations, are responsible for the setting up of the in- 
flammation. Moreover, "Welch pointed out the frequency with which 
the streptococcus is present in such cases associated with the bacillus 
coli communis. He adds that the colon bacillus grows so rapidly and 
abundantly that the minute colonies of the more important strepto- 
cocci are often overshadowed, and thus may escape observation. 



26 ASEPTIC SURGICAL TECHNIQUE. 

blue color. Plate L, Fig. 6. The organism is widely 
distributed, and " epidemics of blue pus " are not in- 
frequently seen in hospitals. For some time it was 
thought not to possess any pathogenic power, but was 
believed to be simply a concomitant of the pyogenic 
bacteria. It is generally conceded now, however, that 
this micro-organism is pyogenic as well as chromo- 
genic in its action, and it has been found to be 
capable of setting up a general infection in rabbits. 
Comparatively recently it has been demonstrated that 
general infection with the bacillus pyocyaneus some- 
times occurs in human beings. 

The bacillus tetani is an anaerobic bacillus discovered 
by Mcolaier, and first isolated in pure culture by 
Kitasato. Plate I., Fig. 7. Its natural habitat is the 
soil. It is commonly present in the faeces of herbiv- 
orous animals. The organism is not a pus-producer, 
and does not become distributed over the body, but 
develops in loco, and it is to the absorption of its tox- 
ines into the general system that the symptoms of 
the disease are due. Fortunately, tetanus is now a 
comparatively rare complication in surgery. 

The bacillus tuberculosis does not belong to the group 
of pyogenic organisms, and only rarely has to be con- 
sidered in the infection of wounds. Plate I., Fig. 8. 
As it is concerned, however, in a certain proportion 
of cases of peritonitis and in some diseases of the geni- 
talia, we have thought it advisable to mention it here. 
The properties of this bacillus are so well known that 
we need not describe its history or its general charac- 



PATHOGENIC ORGANISMS. 27 

feristics. It may reach the peritoneum through the 
blood-current, from the intestines, or through the 
lymphatic channels from above. In the genitalia the 
organisms are deposited in the tissues, as a rule, from 
the blood-current, but it is believed that they may 
sometimes enter from below, — e.g., by direct contagion 
from coition. 

The bacillus aerogenes capsulatus, discovered by 
Welch and Euttall, must be mentioned here, as it is 
occasionally met with in gynaecological and other 
surgical cases. This gas-producing bacillus has been 
proved to be responsible for the diffuse septic phleg- 
monous processes (acute spreading gangrene) so often 
associated with the production of gas in the tissues. 
(E. Fraenkel.) It is not a pus-producer in itself, but 
sometimes occurs along with the ordinary pyogenic 
bacteria, in which cases there results a mixed infection. 
It is capable, however, alone of causing spreading 
gangrene, an extremely dangerous condition, and one 
which nearly always terminates fatally. Ernst has 
described a case of fatal septic endometritis following 
abortion, in which at the autopsy the walls of the 
uterus were found to be gangrenous and contained 
bubbles of gas; there were necrotic nodules sur- 
rounding cavities filled with gas which were scattered 
throughout the liver and heart muscle ; large numbers 
of these bacilli existed wherever the presence of gas 
was demonstrable. Another case of general infection 
with the bacillus aerogenes capsulatus following abor- 
tion, associated with general subcutaneous emphysema 



28 ASEPTIC SURGICAL TECHNIQUE. 

and accumulations of gas in the blood-vessels all over 
the body, was fully reported in this country in 1894 
(Steward, Baldwin, and Graham), and the organism 
is now recognized as being of considerable pathogenic 
importance. In order to isolate this bacillus anaerobic 
methods have to be employed. It varies in length from 
seven to nine micro-millimetres, is encapsulated, non- 
motile, and sometimes forms spores. Pelvic abscesses 
are sometimes found which contain gas, and in such 
cases the possibility of the presence of this bacillus 
should always be taken into consideration. 

When, after an abdominal section, the patient has 
died without having exhibited the characteristic symp- 
toms of septicaemia, the death has not usually been 
attributed to septic infection, but rather has been 
supposed to be due to "heart-failure," shock, pneu- 
monia, suppression of the urine, or some other more 
or less satisfactory cause. But when a patient dies 
even less than twelve hours after an operation we 
cannot positively exclude sepsis as the cause of death 
until the fact has been proved by an autopsy made by 
a competent pathologist and bacteriologist. 

Autopsies are on record at which none of the local 
lesions which attend septic inflammation were demon- 
strable to the naked eye. The examination of cover- 
slips, however, made from a small amount of fluid in 
the pelvic cavity, showed that organisms were present 
in large numbers, and tubes of nutrient agar-agar in- 
oculated with the same fluid gave the characteristic 
growths. 



ASEPSIS. 29 

Experiments have shown that the poisoning result- 
ing from a peritoneal infection is sometimes so intense 
as to cause death before the appearance of any marked 
local reaction in the peritoneum. In the fatal cases 
in which it has been impossible to secure a complete 
autopsy, even where during life the ordinary symptoms 
of such a condition were absent, we have not the right 
to state positively that death was not due to septic in- 
fection. 

It is undoubtedly more comforting to the operator 
to attribute a fatal result to any cause other than this, 
since he is naturally unwilling to think that his tech- 
nique has been faulty. Those surgeons who are best 
able to judge are perhaps most ready to admit the pos- 
sibility of infection of the wound through some slip 
during the operation, since it is they who realize the 
manifold ways in which such an accident might occur. 

In practising asepsis we aim at bringing about that 
condition in which there is complete absence of septic 
material, — a condition which, of course, can be insured 
only by excluding all pathogenic micro-organisms 
from the site of operation. 

By this we do not mean to say that in the most 
complete asepsis to which we attain there is always a 
sterile wound; on the contrary, as we have already 
stated, it is probable that most fresh wounds contain 
a certain number of organisms, but these are either 
non-virulent or are present in too small numbers to 
give rise to the phenomena of sepsis. 



30 ASEPTIC SURGICAL TECHNIQUE. 

The maintenance of an aseptic condition is certainly 
one of the most important points to be aimed at in 
formulating a technique of operative surgery. It is 
true that an ideal technique which will be aseptic from 
a bacteriological stand-point, and which will protect 
our wounds so as to prevent the ingress of even a 
single bacterium, is scarcely ever possible, at least at 
the present day ; but those who control their technique 
by bacteriological experiments, and strive in every 
way to approach as nearly as possible such an ideal, 
constantly aiming at perfect cleanliness in their work, 
will undoubtedly obtain better results than those who 
have no such standard. 

In practising antisepsis we employ the various means 
which have been devised for destroying bacteria or for 
so inhibiting them in their action as to render them 
incapable of giving rise to infection. The agents 
which are employed to bring about this condition 
are known as antiseptics and disinfectants. 

Strictly speaking, antiseptics must be classed sepa- 
rately from disinfectants, the latter term applying 
only to those agents which kill pathogenic or putre- 
factive organisms, and which may consequently be 
termed true germicides, the former to the agents 
which arrest putrefaction or fermentation, but do not 
necessarily destroy the micro-organisms. A deodo- 
rant does away with bad odors, and does not neces- 
sarily have either disinfectant or antiseptic powers. 

While the bacteriologists have shown us that infec- 



MECHANICAL TECHNIQUE. 31 

tion rarely takes place from the air, they have also 
demonstrated that it is most frequently brought about 
by contact. We can thus readily understand the com- 
parative uselessness of the carbolic spray, and the im- 
portance of preventing the introduction of bacteria 
on the instruments or the hands of the operator and 
his assistants. 

The association of laboratory with operative clinical 
experience must continue; we have learned much, 
but there is a promise of still greater progress to be 
reached in this way. While deprecating the adoption 
of methods based solely upon laboratory experiments, 
experience having too often shown the inexpediency 
of such a procedure, I would insist most strongly 
upon the necessity of the harmonious working together 
of the surgeon and clinician with the bacteriologist, 
believing that each and all will in this way gain new 
facts and new points of view. 

But in our enthusiasm for asepsis and aseptic 
methods we must not by any means lose sight of the 
importance of a perfected mechanical technique. 

Besides depending upon the presence or absence of 
the seed, — the bacteria, — the question of infection or 
immunity is influenced to a great extent by the con- 
dition of the soil, — the tissues and fluids of the in- 
dividual. Our more modern knowledge of wounds 
and wound-infection should by no means tend to 
make us belittle the skill of the surgeon, and at the 
same time it should stimulate him to increase his 
operative precision. 



32 ASEPTIC SURGICAL TECHNIQUE. 

Linear incisions, the avoidance of any rough handling 
of the tissues and of the use of irritating fluids in the 
wounds, the filling of dead spaces with substances 
having their origin in the body (serum, moist blood- 
clot, known to have definite germicidal power), the 
abbreviation of the time required for operations, the 
maintenance of hygienic surroundings, and the adop- 
tion of every means for strengthening the vital re- 
sistance of the patient — all contribute largely to a 
surgeon's success. 



CHAPTER II. 

PRINCIPLES OF STERILIZATION — DRY AND MOIST HEAT — FRAC- 
TIONAL STERILIZATION — CHEMICAL DISINFECTION. 

By the term sterilization, as employed in connection 
with surgical technique, we properly mean a process 
which brings about the absolute and complete de- 
struction of bacteria. 

The most reliable way of destroying infectious ma- 
terial is by the use of the actual flame ; but this, of 
course, can be applied in only a few instances, and, 
fortunately, we have other agents from which to 
make our choice: 1. Heat, (a) dry and (b) moist. 2. 
Chemical disinfectants. 

Any or all of these methods may be supplemented 
by mechanical means, — washing, rubbing, brushing, 
scraping, and the like. 

One may well allow one's self to be guided by the 
modes of procedure adopted in the bacteriological lab- 
oratories, for there the best methods of sterilization 
have been elaborated, inasmuch as the technique em- 
ployed in the sterilization of culture media, to be of 
any use at all, must obviously be devoid of flaws. As 
we shall see, however, the laboratory methods are to 
be used only as a guide, for many ingenious modifica- 
tions of them have to be introduced in order to render 
possible their practical application to operative sur- 

3 33 



34 ASEPTIC SURGICAL TECHNIQUE. 

gery. As a rule, those micro-organisms which do 
not form spores (vegetative bacteria) are killed at a 
comparatively low temperature (58° to 65° C, 136° 
to 150° F.), while the destruction of spore-containing 
bacilli requires higher temperatures and stronger 
chemical solutions. Fortunately, the ordinary pyo- 
genic cocci do not, so far as we know, form spores, 
and so are easily destroyed, in this way differing from 
the tetanus-bacillus and the tubercle-bacillus, which 
belong to the second category. 

It goes without saying that, before any further at- 
tempt is made to proceed to the sterilization of an 
object, all extraneous material is as far as possible to 
be removed by the ordinary mechanical methods. In 
my remarks upon the different methods of sterilization 
to be employed, those which may still be considered 
to be sub judice will be disregarded, and only those 
procedures will be described which have proved them- 
selves by their effectiveness and the reasonableness of 
their cost to be suitable for recommendation to the 
practical surgeon. 

Sterilization by fire — i.e., by means of the actual flame 
— is used by the surgeon only on very rare occasions, 
except for doing away with worthless and dangerous 
objects, such as soiled dressings, and need not be dis- 
cussed at length here. 

For the carrying out of sterilization by means of dry 
heat a " hot-air sterilizer" is required. This consists 
of an oven made of sheet-iron with double walls, and 
fitted with shelves, on which the articles to be sterilized 



DRY HEAT. 



35 



Fig. 1. 



are placed. (Fig. 1.) The heat is supplied by a rose or 
tulip gas-burner beneath, and the temperature is regis- 
tered by a thermometer 
which passes through 
the roof of the oven. 
To kill the ordinary 
vegetative (non-spore- 
forming) bacteria, ex- 
posure to dry heat at a 
temperature of 100° C. 
(212° F.) for one hour 
and a half is sufficient; 
but where spores exist a 
temperature of 140° C. 
(284° F.) for three hours 
is necessary. Unfortu- 
nately, the process of 
sterilization by means of 
dry heat destroys many 
substances of vegetable or animal origin, and has now, 
even in the disinfection of metal instruments, been 
supplanted by more convenient and speedy methods. 
Dry heat does not permeate the substance to be ster- 
ilized nearly so thoroughly as steam heat, and is in 
consequence much more difficult to control. It still, 
however, finds an important application in the steril- 
ization of glassware. 

In the sterilization by means of moist heat, one of the 
quickest agents which we possess is boiling water. 

The ordinary pyogenic cocci and other vegetative 




w 

Hot-air sterilizer. 



36 



ASEPTIC SURGICAL TECHNIQUE. 



Fig. 2. 



bacteria are killed by it in from one to five seconds, 
while anthrax spores succumb in about two minutes ; 
and while it is true that there are spores which are 
much more resistant, these are not pathogenic for 
human beings, so that we may safely say that exposure 

to the action of briskly 
boiling water for from 
fifteen to thirty min- 
utes will almost cer- 
tainly insure complete 
disinfection. 

Sterilization by steam 
is another simple and 
practical method. To 
insure success an appa- 
ratus must be used in 
which all the air is ex- 
pelled from the cham- 
ber by the steam and 
an even temperature of 
100° C. (212° F.) can 
be maintained through- 




Tanks for storage of hot and cold water 
(Kelly). 



out. 
Several 



kinds of 

steam-sterilizers have been recommended. One of 
the cheapest and most convenient is the copper steril- 
izer of Arnold, made by Wilmot Castle & Co., Roch- 
ester, New York. This is especially useful for steriliz- 
ing bandages and gauze dressings, and is so generally 
known that it need not be described here. 



MOIST HEAT. 
Fig. 3. 



37 




Steam-sterilizer (Kny-Scheerer). 

Another form of steam-sterilizer which has given 
very satisfactory results is represented m F* 3. In 



38 



ASEPTIC SURGICAL TECHNIQUE. 



hospitals or other places where large quantities of 
clothing and other materials have to be sterilized at 
one time large steam disinfectors must be set up. 

Fig. 4. 



m INc» 




Steam-sterilizer (in section). 

For quick and thorough disinfection steam under 
pressure is employed. (Fig. 4.) 

One of the most ingenious methods of insuring com- 
plete disinfection is that known as fractional or discon- 
tinuous sterilization. If a fluid be kept at a temperature 
of 100° C. (212° F.) in a steam-sterilizer for twenty 
minutes, all vegetative forms of bacteria will be de- 



FRACTIONAL STERILIZATION. 39 

stroyed. If this fluid then be kept for twenty-four 
hours at the ordinary room or body temperature, any 
spores which have escaped destruction (certain spores 
are known to resist a two hours' exposure to stream- 
ing steam) at the first heating will have grown out 
into vegetative forms, and can then be killed by a 
similar exposure on the second day. If the process 
be repeated for a third time, one can be reasonably 
sure of having secured a completely sterile fluid. Tyn- 
dall, Pasteur, and others have shown that complete 
sterilization is practicable with the use of much lower 
temperatures (60° C, or 140° F.), if the process is 
repeated on three or four successive days. 

While, as has been said, steam sterilization, where 
applicable, is a most reliable and satisfactory method, 
we can see at once that its universal employment 
is out of the question. For example, to use steam 
heat for the disinfection of the hands of the operator 
and of his assistants is impossible, neither can it be 
employed for the body of the patient to be operated 
upon. Again, it must not be used in the sterilization 
of objects made of leather or rubber, as these sub- 
stances are destroyed by it. 

On no subject in surgery have the opinions of men 
changed so much, perhaps, as upon the value and 
sphere of usefulness of the "individual antiseptic," 
and the zeal of imperfect knowledge is responsible 
for much of the opprobrium which has been thrown 
by some upon the " antiseptic" treatment of wounds. 



40 ASEPTIC SURGICAL TECHNIQUE. 

The ideal chemical disinfectant will be one that can 
be readily employed for a variety of purposes, so as 
to be generally useful in practice ; it should be easily 
soluble in water and inexpensive ; it should possess 
active germicidal powers, and not simply lead to the 
arrest of the development of bacteria ; it should exert 
a sufficient action within a reasonably short space of 
time ; it should not injure the substances to be disin- 
fected, and should be of such chemical composition 
that it cannot be easily decomposed or rendered inert 
by chemical combination with the substances to be 
disinfected; and, finally, it should not endanger those 
who handle it, nor possess any very unpleasant odor. 
A careful study of the properties of the ordinary 
chemical disinfectants in use will soon convince any 
impartial observer of the many deficiencies of the best 
of them when judged by this standard. 

Carbolic acid is a powerful antiseptic, but a dangerous 
one. In fact, there are no antiseptics of much power 
which can with impunity be poured into a wound. 
The day has come when we must relegate the use of 
antiseptics to the period before an operation, and rely 
during the operation on the maintenance of an aseptic 
condition. Antisepsie avant V operation, asepsie pendant 
(Terrillon). 

Carbolic acid is a fairly stable body, and has the 
advantage of being readily soluble in water (up to the 
strength of five per cent.) with the aid of heat. If 
the solutions are made with cold water, it is advisable 
to add an amount of alcohol or glycerin equal to that 



CHEMICAL DISINFECTANTS. 41 

of the acid employed. Carbolic acid, besides being 
a disinfectant, is also a deodorizer and local anaesthetic. 
It is well to keep a two-and-a-half-per-cent. and a five- 
per-cent. solution always on hand. The dressing 
recommended by Keith for coeliotomy wounds, now no 
longer employed, consisted of one part of pure carbolic 
acid mixed with fifteen parts of glycerin. Solutions 
of carbolic acid in oil have no antiseptic value. 

Corrosive sublimate (mercuric chloride, HgCl 2 ) for a 
long time has occupied a prominent place in the list 
of disinfecting agents, but the deductions drawn from 
the experiments at first made with it have been proved 
to be incorrect. Koch asserted that a single applica- 
tion of it for but a few minutes, without any previous 
preparation of the objects to be disinfected, guaranteed 
an absolute disinfection even in the presence of the 
most resistant organisms. Gartner and Fliigge, Behr- 
ing, Tarnier, and Yignal thought they had shown that 
the yellow staphylococci were killed in from a few 
seconds to as many minutes by exposure to the action 
of a one to one-thousand solution of corrosive subli- 
mate ; but after Geppert had drawn attention to the 
fallacies of these early experiments, our views on the 
value of bichloride of mercury as a disinfectant under- 
went a material change. Geppert showed that the 
principal source of error lay in the failure to guard 
against carrying over, together with the bacteria which 
had been exposed to its action, enough of the sublimate 
to prevent the growth and development of the organ- 
isms in the nutrient media to which they were trans- 



42 ASEPTIC SURGICAL TECHNIQUE. 

ferred for the purpose of determining whether or not 
they had been killed. He found, by precipitating the 
mercury with a solution of ammonium sulphide and 
thus converting it into the insoluble and inert sulphide, 
not only that the pyogenic bacteria had not been killed, 
but that they often still possessed the power of setting 
up disease in animals. 

In order to see how far these objections were appli- 
cable to surgical disinfection, Abbott, working in Pro- 
fessor Welch's laboratory, repeated the experiments 
with sublimate, with particular reference to the pyo- 
genic organisms, observing most carefully the precau- 
tions indicated by Greppert. He found that even under 
the most favorable conditions a given amount of subli- 
mate had the property of rendering inert only a given 
number of individual organisms, the process being a 
definite chemical one, consisting' in a combination of 
the sublimate with the protoplasm of the bacterial cell. 
He also found that the disinfecting power of the sub- 
limate is profoundly influenced by the proportion of 
albuminous material present in the medium contain- 
ing the bacteria, and that while certain organisms 
(yellow staphylococci) after exposure to sublimate may 
undergo a temporary alteration, these effects may be 
made to disappear by successive cultivations in normal 
media. 

The extreme toxicity of sublimate is so well known 
and so generally appreciated that it would scarcely be 
necessary to mention it were it not that many un- 
doubted and probably some unsuspected cases of death 



CHEMICAL DISINFECTANTS. . 43 

from sublimate-poisoning have occurred following the 
irrigation of wounds with too strong solutions of this 
substance. Besides showing the general toxic effects, 
the experiments relating to the local injury done to 
the tissues by chemical disinfectants are full of inter- 
est, inasmuch as it has been definitely proved that the 
local necroses caused by these chemical irritants favor 
the multiplication of the micro-organisms of suppura- 
tion. Thus it has been shown that irrigation of fresh 
wounds with a solution of bichloride of mercur} r as 
weak as one to ten thousand is followed by a distinct 
line of superficial necrosis, which can easily be de- 
monstrated under the microscope, and it is readily 
conceivable that solutions even much more dilute may 
render inert those delicate processes by means of 
which the cells and tissue fluids exert a germicidal 
power. The ill effects, then, whether general or local, 
which may follow from its toxicity, to say nothing of 
its inefficiency, would seem absolutely to preclude the 
use of corrosive sublimate for irrigation in the case 
of fresh wounds. Moreover, it must now, even as 
an agent for the external disinfection of inanimate ob- 
jects, rank much lower than formerly. As, however, 
it is required for certain purposes, it is well to keep a 
supply on hand. The most convenient strength for a 
stock solution is five per cent., which can be made by 
dissolving with the aid of heat fifty grammes (770 
grains) of sublimate and the same amount of common 
salt in one litre (33 J ounces) of distilled water. From 
this the solutions required for use can be made in a 



44 ASEPTIC SURGICAL TECHNIQUE. 

moment by dilution with a proper amount of water ; 
thus, twenty cubic centimetres (5J drachms) of the 
stock solution with the addition of enough distilled 
water to make one litre (33} ounces) give approxi- 
mately a one to one-thousand solution. The use of 
distilled water and the addition of salt are necessary in 
their preparation, since otherwise, if sublimate solu- 
tions are allowed to stand, the mercuric salt is gradu- 
ally transformed into an inert oxychloride. 

Potassium permanganate, in solutions varying in 
strength from one to one hundred to one to ten, pos- 
sesses some germicidal power. This is materially en- 
hanced by an after-treatment with sulphurous or oxalic 
acid. It has been suggested that its effects are due to 
a process of oxidation. Reference will be made to the 
mode of its application when we deal with the disin- 
fection of the skin. 

Formalin. — This is a forty per cent, solution of for- 
maldehyde, which was introduced in 1894. It is some- 
times used especially for the disinfection of clothing, 
leather materials, brushes, and books. The materials 
are exposed to the vapor for twenty-four hours, and 
afterwards treated with ammonia to remove the dis- 
agreeable odor of the formalin. It certainly possesses 
antiseptic powers, but it is slow in its action. There 
appears to be no likelihood that it will take a promi- 
nent place in surgical technique unless it finds appli- 
cation as a preservative fluid, one part to ten thousand 
preventing the development of putrefactive bacteria. 

Other chemical disinfectants, such as solutions of boric 



CHEMICAL DISINFECTANTS. 45 

acid, of naphthol, chloral, and salicylic acid, are of 
questionable usefulness, and, as will be seen when we 
treat of the methods advised for practical disinfection, 
are of extremely little value ; they may therefore be 
dispensed with by the surgeon in his operations. 
Preparations of cresol, lysol, and other coal-tar deriva- 
tives may sometimes be convenient as deodorizers, 
but are not to be relied upon as disinfectants. 



CHAPTER III. 

PRACTICAL APPLICATION OF THE PRINCIPLES OF STERILIZA- 
TION — OPERATING SUITS — PREPARATION OF THE SURGEON 
AND HIS ASSISTANTS. 

The principles to be followed by the surgeon in 
formulating for himself a scientific technique have 
been already indicated. The necessity of paying at- 
tention to the most minute details has been insisted 
upon, and enough has been said to show that the 
smallest slip may invalidate the whole procedure. 
But however well trained and skilful he himself may 
be, it is easy to understand how dependent an opera- 
tor is upon those about him for the prevention of 
technical errors. It is only by choosing assistants 
who are thoroughly imbued with the strictest ideas of 
asepsis, who are willing to learn and are enthusiastic 
in their work, that he can hope to receive much 
aid from them. And after a surgeon has surrounded 
himself with desirable and faithful assistants, he will 
find it advantageous repeatedly to review and drill 
them in the minor points. Above all, he should, 
by setting a good example, endeavor to keep every- 
thing up to the mark and to establish a system of 
intelligent routine. Any good work necessarily in- 
volves a great deal of drudgery, and in the technique 
of the newer surgery the lazy man has no place. 
46 



OPERATING SUITS. 47 

A daily bath and special attention to personal hygi- 
enic measures are essential to all who work in the 
operating-room. The tax on the physical powers of 
those who operate several times a week is by no means 
light, and it is only with the best care of his personal 
health that a surgeon, even when naturally strong, 
will be able to maintain his full physical vigor. 

It will be necessary to provide for the operating- 
room a sufficient number of suits especially adapted 
for the purpose, and made of some material which 
can be easily sterilized. For now that we know the 
dangers of infection by contact, it would seem essen- 
tial that not only the surgeon but all of his assistants 
should wear at every operation thoroughly clean ster- 
ilized suits. During an operation the sleeve or some 
other portion of the dress may come in contact with 
the field of operation, or one of the surgeons may acci- 
dentally touch the clothing of one of his fellows, and 
thus, if the suits are not sterile, pathogenic micro- 
organisms may readily be introduced into a wound. 
It is safer and better that all should put on a complete 
change of costume rather than simply draw on a ster- 
ilized coat and pair of trousers over the ordinary 
clothes, as has been recommended by the German 
school. The former plan also offers many advantages, 
for not only are the warm out-door clothes exchanged 
for thin, cool garments, which are far better suited for 
the temperature of the operating-room, but the ordi- 
nary clothes run no risk of being soiled or of carrying 
away on them the disagreeable odor of the fumes of 



48 ASEPTIC SURGICAL TECHNIQUE. 

the anaesthetic. Besides this, such suits afford much 
better protection against infection and are not nearly 
so cumbersome and awkward to work in as a sheet 
or rubber apron. They are best made of some white 
material that can be easily and thoroughly washed. 
Twilled muslin, costing about thirteen cents per yard, 
is perhaps the most serviceable for this purpose. The 
suits should be made to fit comfortably and should be 
fairly loose, so as not to impede the movements in any 
way. They can be made in one piece like a bathing- 
suit, with buttons down the front, and with a belt at- 
tached to the waist. The sleeves of the jacket should 
extend to just above the elbow-joint. (Fig. 5.) It 
is more usual, however, to have them made in two 
separate parts, consisting of a shirt (or jacket) and a 
pair of trousers. The jacket can be made so as to 
button down either the front or the back, the former 
arrangement being probably the more convenient. 
The trousers should not be long enough to allow the 
bottoms to drag on the floor. To sterilize these suits 
it is not sufficient to trust to the washing that has 
been given them in the general laundry, as even after 
this they could easily contain infectious material from 
coming in contact with the hands of those employed 
in ironing and afterwards folding them. In order to 
do away with this source of danger, it is necessary 
that they should be thoroughly sterilized before they 
are worn. This can be done by wrapping them in a 
towel or by placing them in bags made of butcher's 
linen, and then exposing them to the streaming steam 



OPERATING SUITS. 



49 



of the sterilizer for half an hour. They can then be 
taken out of the sterilizer and allowed to dry on a 
clothes-line which has either been sterilized or which 
is covered with sterilized cloths or towels. Or, better 

Fig. 5. 




Suits worn by operator and nurse. 

still, this step can be dispensed with by using the 
autoclave, in which they are sterilized and then left 
to dry. After they have been thoroughly dried they 
may be put away in dry sterilized towels or bags 
until they are required for use. The nurse or assist- 
ant who attends to the sterilization of these suits 

4 



50 ASEPTIC SURGICAL TECHNIQUE. 

should, of course, after the process is completed, be 
careful not to nullify the results in putting them 
away. Danger can be easily avoided by protecting 
the hands with rubber gloves which have been 
soaked in a one to five hundred aqueous solution of 
bichloride of mercury before being used. The steril- 
ization should be done some time before the suits are 
required for use, so that they may have time to be- 
come thoroughly dry, a process which will generally 
be found to take three or four hours. 

The operator, his assistants, and the nurses should 
wear white canvas shoes with low tops and with rubber 
soles. They are clean and noiseless, and by their em- 
ployment the soiling of the street shoes during an 
operation is avoided. They can be easily cleaned by 
washing them oft' with hot water, and a coating of 
pipe-clay will give them a very neat appearance. 

When putting on the operating suits, care must be 
taken to allow the hands to come in contact with the 
clothing as little as possible. All the ordinary cloth- 
ing should be first removed, then the white shirt and 
trousers are carefully put on, the shoes being adjusted- 
last of all. 

In hospitals there should be a dressing-room adjoin- 
ing the operating-room. Too much attention cannot 
be paid to the minor points of personal cleanliness. 
It is important to keep the head and face scrupulously 
clean. The hair of the head should not be allowed to 
grow long, and should be kept as free as possible from 
dandruff. It has been suggested that the surgeon will 



DISINFECTION OF THE SKIN. 51 

do well to moisten the hair before an operation, since 
particles of dust might easily fall down from his head 
into the open wound, and thus, particularly if some 
inflammatory condition of the scalp were present, 
might produce a dangerous infection. Sterilized mus- 
lin caps or fillets may be worn. If he be willing, the 
surgeon had best be clean shaven. A heavy beard 
should never be permitted in close proximity to an open 
wound. The finger-nails should be kept well trimmed, 
for a long nail at times does a great deal of injury by 
scratching and otherwise injuring the tissues. They 
should not be cleaned with the blade of a knife, as 
this will wound the matrix. A bit of wood or ivory 
shaped like a toothpick, or even a match shaved 
down, will answer very well. 

Since Eberth, in 1875, demonstrated the presence 
of large numbers of bacteria in normal sweat, mauy 
experiments have been made in this direction, and as a 
result our ideas with regard to the surgical disinfection 
of the skin have been more or less completely over- 
turned. Several different kinds of bacteria have been 
found upon the surface of the human body, and a 
whole bacterial flora for this region has been described. 
Attempts have been made to determine whether or 
not any particular kind or kinds of bacteria are con- 
stantly present there. The results of the European 
investigators on this point are more or less at vari- 
ance. Bordoni has even advanced the view that 
groups of men in every country have a peculiar bac- 
terial flora of their own upon the body surface, and 



52 ASEPTIC SURGICAL TECHNIQUE. 

that the flora varies with the occupation. The ex- 
periments made in the Pathological Laboratory of 
the Johns Hopkins University have been rewarded 
with the isolation of a form of bacterium which has 
been found to be almost constant in the skin. This 
variety is a white staphylococcus, and has been named 
by Professor Welch the staphylococcus epidermidis 
albus, to which reference has been made above. 
(Chapter I.) The significance of these investigations, 
as bearing upon the disinfection of the hands and 
forearms of the surgeon and his assistants, can hardly 
be overestimated, and we cannot but feel that the 
question of this disinfection has not even now re- 
ceived the consideration which it deserves. The gist 
of the matter is contained in the following sentences 
which we have taken from Dr. Welch's article. 
" Since the institution of bacteriological control as a 
test of the sufficiency of surgical technique, many 
methods before believed to be reliable have been 
proved to be faulty. We are past the days when an 
ordinary washing of the hands with soap and water 
followed by a dash of sublimate solution sufficed to 
put them in a condition to enter a clean wound. 
Numerous experiments that have been made with a 
view of ascertaining the best methods of accomplish- 
ing the sterilization of the hands show that it is indeed 
a difficult matter to effect it, and especially to insure 
the destruction of micro-organisms which lie beneath 
the finger-nails." 

Fiirbringer, in an extended series of experiments in 



DISINFECTION OF THE SKIN. 53 

1888, found that a preliminary cleansing with soap 
and water together with a vigorous use of the brush 
was even more important than the subsequent em- 
ployment of a disinfectant solution. His method of 
disinfecting the hands is as follows : (1) The nails are 
kept short and clean. (2) The hands are washed and 
scrubbed thoroughly for one minute with soap and hot 
water. (3) They are next washed for one minute in 
alcohol at 80° C. (176° F.), in order to remove all 
fatty and oily substances. (4) They are then scrubbed 
for one minute in a warm solution of carbolic acid 
(two per cent.) or of sublimate (one to five hundred). 

I fully concur with Fiirbringer's suggestion that 
the effects of cleansing with soap and brush, the water 
used being as hot as it can be borne, are of more 
value than those obtained from the employment of 
disinfectant solutions. In this mechanical removal of 
organisms we have therefore an agent of the first 
importance. This fact the author has demonstrated 
many times in the following way. Cultures were 
taken from the hands before the scrubbing was begun 
and then several times again at different periods of the 
process, the results showing that the longer we scrub 
with soap and water the fewer the number of bacteria 
which are left. Cultures taken after scrubbing for 
ten minutes always showed a less number of bacteria 
than those taken after five minutes' work had been 
done on the hands. 

The inefficiency of chemical disinfectants has shown 
the necessity of bringing about as thorough a removal 



54 ASEPTIC SURGICAL TECHNIQUE. 

of the bacteria as is possible by the mechanical action 
of the scrubbing, and of not trusting too much to 
these uncertain chemical agents, which henceforth 
must play a subordinate role in disinfection. 

Not only, then, must the operator and his assistants 
but all those who in any way aid in the handling of 
the materials that are employed during an operation 
be very thorough with the cleansing of their hands. 
A French surgeon has gone so far as to state that in 
ninety-nine cases out of a hundred, when infection 
takes place, it occurs during the operation, from the 
instruments, the hands of the surgeon, the sutures, 
the sponges, the dressings, or from the patient herself. 

Furbringer'a method, when conscientiously carried 
out, yields fairly good results, but it has been shown 
that if the mercury is precipitated with ammonium 
sulphide, and scrapings taken from the skin which 
has been thus prepared are placed in nutrient media, 
the presence of numerous living bacteria can still be 
often demonstrated. 

After applying bacteriological tests to the methods 
usually employed, we have found the following to be 
the most reliable. The operating-room suit with the 
short sleeves having been put on, the hands and fore- 
arms are scrubbed vigorously for ten minutes by the 
watch with a stiff brush, previously sterilized by steam, 
and with green soap, the water used being as hot as 
can be borne and being changed at least ten times. In 
order to avoid any possible contamination from the ne- 
cessity of turning the spigots off and on with the hands, 



DISINFECTION OF THE SKIN. 



55 



Fig. 6. 




Spigot attachment. 



56 ASEPTIC SURGICAL TECHNIQUE. 

in 1893 I had constructed an arrangement by means 
of which this can be done equally well with the 
feet. (Fig. 6.) The excess of soap is washed off' in 
hot water and the hands and forearms are then im- 
mersed for two minutes in a warm saturated solution 
of permanganate of potassium, which should be well 
rubbed into the skin with the aid of a sterilized swab. 
(Plate II.) They are next washed in a warm satu- 
rated solution of oxalic acid until the stain of the 
permanganate has completely disappeared. The best 
way is to sterilize saturated solutions of potassium per- 
manganate and oxalic acid in large flasks for fifteen 
minutes in the autoclave. Just before the operation 
sufficient quantities are warmed and poured into steril- 
ized basins. The hands and forearms are then rinsed 
off in sterilized water or sterilized salt solution, and 
finally are immersed in a solution of bichloride of 
mercury (one to five hundred) for two minutes. 

At the risk of repetition, it must be insisted again 
that after the hands and forearms have been once pre- 
pared they must on no account be allowed to come in 
contact with objects which are not sterile, or the whole 
work will be undone, since " a chain is no stronger 
than its weakest link." The smallest slip is fraught 
with danger to the patient. 

Just before beginning the operation the hands and 
forearms should be well rinsed in sterilized salt solu- 
tion, to remove any excess of the bichloride. After 
these procedures have been employed, cultures made 
from the scrapings underneath and around the nails, 







P 




DISINFECTION OF THE SKIN. 57 

even after precipitation of the mercury, yield almost 
always negative results. 

It is to be remembered that little or nothing cer- 
tain can be attained unless each step is conscientiously 
carried out. In fact, if practised in a slipshod man- 
ner, an elaborate technique does more harm than good 
by deceiving us with a sense of security which is un- 
warranted. 

The use of sterilized rubber gloves and armlets un- 
doubtedly affords the best means of preventing con- 
tact infection. Although they may at first make the 
operator feel somewhat clumsy, after a little experience 
he will find that they will not materially interfere with 
the delicacy of touch and manipulation. A somewhat 
extended experience has convinced me of the great 
advantages to be derived from their use, and I now 
consider them as essential accessories to an aseptic 
technique, and as eliminating many dangers. 

After the hands and arms have been sterilized, and 
the rubber gloves and armlets adjusted, a sterilized 
short-sleeved gown or a short apron, which covers the 
operator from the shoulders to the thighs, is put on. 
(See Fig. 5.) 

The strict observance of all these details may seem 
to be a tedious and an almost endless task, but when 
we consider how important it is to obtain and preserve 
a condition of surgical cleanliness, we shall not grudge 
any time or trouble spent upon them, and in a short 
while all will become an easy matter of routine. 

There are many other points connected with this 



58 ASEPTIC SURGICAL TECHNIQUE. 

subject to which we might refer. Thus, should the 
operator perspire, the moisture should be removed 
from his face by a nurse with a towel before any drops 
have been allowed to fall into the wound. Talking 
should be avoided over the field of operation, as saliva 
and its accompanying micro-organisms may by some 
accident gain access to the wound. If he can avoid it, 
the surgeon should never operate when he is suffering 
from coryza, or from a catarrh which is accompanied 
by mucous secretions. The handling of a pocket- 
handkerchief makes a break in the technique, — a 
point always to be remembered. It would be impos- 
sible to enumerate here all the contingencies which 
the aseptic surgeon has to meet, and he will have to 
trust to his common sense to teach him to consistently 
apply the principles upon which his whole technique 
is based. 






CHAPTER IV. 

THE PREPARATION OF PATIENTS FOR OPERATIONS, MAJOR AND 
MINOR— MEANS EMPLOYED TO OBTAIN AN ASEPTIC FIELD. 

It is advisable to have a patient who is to undergo 
an abdominal section, or, in fact, any operation, under 
careful observation for some few days, in order that 
we may get some idea of the condition of the different 
organs of the body or of any particular idiosyncrasy 
which she may have, and may be able to follow out 
any indications by which her general condition may as 
far as possible be improved and her powers of resist- 
ance proportionately increased. In some cases rest in 
bed for a few days prior to an operation will be of 
decided advantage. 

In ordinary cases the patient should take a daily 
bath for one or two days prior to the operation. She 
should also receive a daily vaginal douche of a warm 
one- to three-per-cent. aqueous solution of carbolic 
acid. The former will usually be strong enough for 
abdominal cases, and it is perhaps better not to use 
the three-per-cent. solution even in all plastic cases, 
as it not infrequently gives rise to pain. The bowels 
should be opened daily. This can be accomplished 
by gentle laxatives, — e.g., the citrate of magnesium, 
a seidlitz powder, or the compound liquorice powder. 
Twelve or twenty-four hours before the operation a 

69 



60 ASEPTIC SURGICAL TECHNIQUE. 

good purge is given, and two or three hours before 
the patient is placed upon the table the rectum should 
be well emptied by means of a large enema of soap and 
warm water. If the enema is omitted or not given in 
such a way as to prove effectual, the bowels are liable 
to be moved while the patient is on the table, and thus, 
especially in plastic cases, the progress of the opera- 
tion may be very much delayed and danger of infection 
incurred. The doctor should give explicit directions 
to the nurse with regard to this matter. 

Light, nourishing food should be taken, and nothing 
that is liable to upset the stomach should be allowed. 
The patient is generally permitted to have any kind 
of soft food which seems to agree with her during the 
two or three days preceding the operation, except that 
in the last twenty-four hours she is restricted to milk 
or broths made from chicken or mutton, although 
at times stewed fruits are allowed. As a rule, unless 
she is very weak and requires stimulants or nourishing 
broths, she should take nothing by the mouth after 
midnight. Shortly before the patient is anaesthetized 
the bladder should be emptied, and if the urine cannot 
be voided naturally, she should be catheterized. 

In urgent cases, such as those of suppurative peri- 
tonitis or of extra-uterine pregnancy where rupture 
has taken place, there is, as a rule, little or no time for 
any preparation before the anaesthetic is administered. 
In any case, however, an enema should be given. 

The further preparation of the patient for an ab- 
dominal section is about as follows. On the night 



PREPARATION OF THE PATIENT. Q\ 

preceding the operation the abdomen and pubes, after 
being thoroughly shaved, are scrubbed with soap and 
water, next with equal parts of alcohol and ether, in 
order to remove all oily and fatty substances, and 
finally with a solution of bichloride of mercury (one 
to one thousand). 

The field of operation is now covered with a thin 
poultice of green soap, which is allowed to remain on 
for from one to three hours, according to the degree 
of sensitiveness of the skin. The soap is removed by 
scrubbing the parts with a brush and hot water, so as 
to get rid of as much epithelium as possible. A large 
compress wrung out of a warm bichloride solution 
(one to one thousand) is then applied to the abdomen 
and held in place with a bandage. 

To summarize, the abdomen may be rendered prac- 
tically sterile in all cases if the following procedures 
are adopted. 

1. A bath of soap and water and a vaginal douche 
of a one-per-cent. carbolic acid solution are given daily 
for three days before the operation. 

2. The hair of the abdomen and pubes is shaved on 
the night preceding the day of the operation. 

3. The parts are given a thorough scrubbing with 
(a) soap and water, (b) alcohol and ether, (c) bichloride 
of mercury (one to one thousand). 

4. A poultice of green soap is applied for from one 
to three hours. 

5. The soap is removed by scrubbing with brush 
and hot water. 



62 



ASEPTIC SURGICAL TECHNIQUE. 



6. A compress of bichloride (one to one thousand) 
is applied, and is kept on until the patient is brought 
to the operating-table. 



Fig. 7. 




Robb's aseptic razor, with case. 

The nurse in charge of the case must see that the 
patient is properly attired before leaving the ward and 
that every precaution is taken to avoid all danger of 
her becoming chilled. Over the fresh night-gown a 
warm wrapper should be drawn. Long stockings 
which reach well above the knees are desirable for 
warmth as well as for the avoidance of unnecessary 
exposure. 

After the patient has been anaesthetized and placed 
upon the operating-table, the compress is removed and 
the following additional steps are carried out. 

1. The field of operation is scrubbed with soap and 
warm sterile water. 

2. It is sponged again with alcohol and ether. 

3. In some cases it is washed with solutions of per- 



PREPARATION OF THE PATIENT. 63 

manganate of potassium and oxalic acid, as in the dis- 
infection of the hands, and subsequently irrigated with 
warm sterile water or salt solution. 

4. It is irrigated with one litre of a solution of 
bichloride of mercury (one to one thousand). 

5. It is irrigated with sterilized salt solution to 
remove any excess of sublimate. 

The rules for diet and preliminary preparations for 
both major and minor operations have been given 
above. We should aim at as thorough an aseptic tech- 
nique in plastic work as in abdominal surgery. While, 
in the majority of instances, faults in technique are 
not so often associated in these so-called minor cases 
with disastrous consequences as when the same errors 
have been committed in abdominal sections, yet there 
are many instances on record of death from sepsis fol- 
lowing upon a simple plastic operation ; and could we 
properly analyze the list of cases in which the fatal 
outcome has been attributed to pneumonia, to lesions 
of the kidney or other organs, their number would 
undoubtedly be much augmented. In not a few ob- 
scure cases in which death has followed a plastic 
gynaecological operation, a thorough autopsy, together 
with a careful bacteriological examination, have de- 
monstrated that death was due to an infection with pyo- 
genic bacteria. Many of the cases which we have been 
inclined to regard as cases of acute nephritis are now 
known to be cases of infection with associated acute 
lesions of the kidney. I may cite a case here which 
recently came under my notice, where it was possible 



64 ASEPTIC SURGICAL TECHNIQUE. 

to show beyond doubt that pyogenic micro-organisms 
had found an entrance at the site of a perineal opera- 
tion. A woman fifty-eight years of age, six weeks 
after a perineorrhaphy gradually developed symptoms 
suggestive of a nephritis. Examination of the urine 
showed the presence of albumin and of hyaline and 
granular casts. She gradually grew worse and died 
a week later in coma. At the autopsy minute ab- 
scesses were found in the heart muscle, in the liver, 
spleen, kidneys, and intestines, and agar-agar Esmarch 
tubes made from these organs gave in every case a 
pure culture of the staphylococcus pyogenes aureus. 
The portal of entrance was found to have been the 
deep perineal tissues, where, just beneath the line of 
the wound, small collections of pus were found. Ex- 
ternally, the wound appeared to have healed perfectly. 

Death has more than once followed as a result of 
apparently trivial operations upon the uterus, cervix, 
and vagina, and this fact should teach us that no 
operation, however insignificant it may seem, should 
be lightly undertaken or carried out without due 
regard for the dangers of infection. As a rule, it is 
difficult to have the field of operation thoroughly clean 
and to keep it so during these minor operations. Still, 
although this is even more difficult to accomplish than 
in abdominal cases, the attempt must be made. 

On the previous evening the parts are carefully 
shaved and scrubbed with soap and water ; they are 
then washed off with sterilized water, and afterwards 
with a solution of the bichloride of mercury (one to 
one thousand). 



PREPARATION OF THE PATIENT. 65 

After the patient has been placed upon the oper- 
ating-table, the vagina, perineum, and external geni- 
talia are to be thoroughly scrubbed with oleine soap 
and sterilized water. This should take at least from 
three to five minutes ; a liberal supply of soap should 
be used, and it should be well rubbed into the 
skin. In order to cleanse the vagina, a small ob- 
long piece of soap is introduced well into the cav- 
ity and the suds rubbed thoroughly into the walls, 
or a large piece of absorbent cotton, held with a 
sponge-holder or bullet-forceps, can be used as a swab. 
Next follows an irrigation with 250 cc. of a ten-per- 
cent, solution of creolin and finally with warm sterile 
water. The excess of soap having been washed off 
with warm sterile water, the external parts are rinsed 
with a litre of warm (one to one thousand) aqueous 
solution of bichloride of mercury, and finally with 
sterilized water or salt solution. If there are large, 
protruding hemorrhoids and a considerable surface 
of the rectal mucous membrane is exposed, caution 
is necessary in using the bichloride of mercury, as it 
is easily absorbed and may give rise to toxic effects. 
Under these circumstances it is well to wash out the 
rectum with a solution of permanganate of potassium 
(one to one thousand) morning and evening for two 
days before the operation, while on the morning of 
the operation soap and water only are employed, and 
the parts are finally rinsed off with sterilized water. 
The maintenance of asepsis throughout the operation 
will be discussed more fully later on. 

5 



66 ASEPTIC SURGICAL TECHNIQUE. 

Recently quite a number of surgeons have advocated 
the use of tincture of iodine as the chief antiseptic in 
the preparation of the field of operation. A certain 
amount of experimental work has been done, and it 
is claimed that by its use the skin may be rendered 
surgically clean. 

The technique advocated by Dr. J. Wesley Bovee 
(Am. Jour. Obstetrics and Diseases of Women and 
Children, Ixiv, 1911) is as follows: 

"The dry, untreated skin is painted with 50 per-cent. 
of the officinal tincture of iodine, absolute alcohol being 
used as a diluent. This is done four or five minutes 
before the operation starts, when the patient is at least 
partly anesthetized. A second coat of the same strength 
is applied two minutes later, and a third coat is put on 
after the operation, covering the edges of the incision." 

Some surgeons have used benzine to prepare the 
skin for the first coat of tincture of iodine. Another 
technique is as follows : A full bath is given at 7 p. m., 
the night before operation. At 7 a. m., the site of the 
operation is carefully scrubbed with green soap and 
sterile water, and then shaved. Alcohol and ether 
are applied, and ether is evaporated till the surface is 
absolutely dry. A coat of a 25 per-cent. dilution of 
the officinal tincture of iodine (2 per-cent. crystallized 
iodine) is applied and allowed to dry. The surface is 
then protected with a sterile towel. One hour later, 
8 a. m., a second coat of the tincture of iodine is applied. 
This, too, is protected by a sterile towel till the patient 
goes on the operating-table about 9 a.m. No further 
preparation is made. 



PREPARATION OF THE PATIENT. (37 

The technique we have used is to shave the abdomen 
24 hours before the operation, the surface being allowed 
to remain quite dry until the patient goes upon the 
table. With the patient under ether, the surface is 
mopped with iodine 1 part in benzine 1000 parts. A 
coat of tincture of iodine 3J per-cent. (50 per-cent. 
officinal tincture) is applied. After this has dried, a 
second coat is painted on, and the incision may then 
be made. 

As a result of personal experiments to test the ster- 
ilizing effect of iodine upon the skin of both dogs and 
human beings, we do not believe that these methods 
are safe. Cultures from the skin after treatment with 
iodine are apt to be sterile, because a certain amount 
of iodine is carried over with the skin into the culture 
medium. This inhibits the growth of the bacteria, even 
if it has not killed them. Accordingly, we removed 
all trace of iodine from the skin before making our 
cultures. As a result, only 6.7 per-cent. of our cul- 
tures from dogs were sterile, whereas 73.7 per-cent. 
were sterile when the cultures were made from skin to 
which iodine still adhered. In human beings 86.4 per- 
cent, seemed to be sterile when some of the iodine was 
allowed to remain, but. only 57.6 per-cent. proved to 
be so after all of it had been removed. Moreover, 
pure cultures of pathogenic organisms were washed in 
various dilutions of the tincture of iodine, freed from 
the iodine, and then planted in culture media and 
incubated. In every case, the organisms proved they 
had not been killed by growing out profusely. 

A clinical indication of the risk of trusting to iodine 



68 ASEPTIC SURGICAL TECHNIQUE. 

for the sterilization of the skin is offered by the heal- 
ing of the incisions in the dogs upon which we op- 
erated. In 86 per-cent. of the cases in which the 
abdomen was prepared by the older method — with 
soap, water and bichloride — we obtained perfect pri- 
mary union. In the cases prepared with iodine, only 
36 per-cent. gave first-intent healing. The results of 
these experiments are described more at length in 
Surgery, Gynaecology, and Obstetrics, September, 1913. 
As a result of this work, we feel that iodine prepara- 
tion of the skin is less trustworthy than the older and 
more complicated method. We believe it should be 
used only in special emergencies. 



CHAPTER V. 



GYNAECOLOGICAL INSTRUMENTS — METHODS OF STERILIZATION — 
INSTRUMENT TRAYS — CARE OF THE INSTRUMENTS AFTER 
OPERATIONS. 

The more modern principles of treating wounds have 
led to certain marked modifications in the surgeon's 
armamentarium, and in no part, perhaps, has the 
change been so pronounced as in the kind of instru- 
ments used in operative work. The day of instru- 
ments with elaborately carved wooden and ivory 
handles is past, and complicated trocars and tubular 
needles no longer have a place in our instrument cases. 
The present tendency is to simplify their construction 
as much as possible and to use no greater variety than 
is absolutely necessary. It is wonderful how much 
can be done by the trained hands and fingers of a sur- 
geon with a very few instruments, even with a scalpel 
and a few pairs of forceps. The choice of instruments 
must necessarily vary with the predilections and train- 
ing of the individual operator. Certain main princi- 
ples, however, should always be kept in mind. The 
surgeon need not encumber himself with such instru- 
ments as are seldom needed, or with a multitude of 
so-called " surgical conveniences" and " automatic 
appliances." He should, however, always provide 

himself with a liberal supply of the instruments in 

69 



70 ASEPTIC SURGICAL TECHNIQUE. 

daily use, in order to be prepared for emergencies. 
None should be retained which do not permit of 
easy sterilization. Knives should have smooth metal 
handles and handle and blade should be in one piece. 
Instruments with grooves, depressions, and notches are 
to be avoided. Good haemostatic forceps with smooth 
blades can now be obtained and are just as effectual 
as the old ones with grooved faces. All scissors, for- 
ceps, needle-holders, and the like should have simple 
articulations, so that the different parts are readily 
separable. An instrument with permanent joints 
cannot be kept surgically clean, and should there- 
fore not be tolerated. A surgeon will often prefer 
to have his instruments well nickel-plated, as they 
have a much better appearance and do not rust easily, 
and, besides, stand better the wear and tear of re- 
peated sterilizations. Since the nickel-plating, how- 
ever, even when double, has been proved to be not so 
valuable as was at first hoped, and instruments which 
are in constant use have soon to be replated, those 
which are used every day need not be nickel-plated, 
for by the methods of sterilization now recommended 
there is comparatively little danger of rust. But for 
those instruments which are not so often used nickel- 
plating is advantageous, since it protects them from 
the action of the air. 

Instruments made of aluminium have been recom- 
mended, but they are undesirable for the following 
reasons : (1) they are too expensive ; (2) they are too 
soft ; (3) they will not stand repeated sterilization. 



PLATE III. 



Fig. 2. 



Fig. 1. 




SJ\ 




Long dressing forceps. (Robb.) 



l)rainage-tube forceps with Kelly's 
lock. 



PLATE IV. 
Fig. 1. 





Haemostatic forceps. 
Fig. 2 




Bullet-forceps. 



PLATE V. 
Fig. 1. 




Fig. 2. 




Needles. 



Fig. 3. 




Transfixion needles. 



INSTRUMENTS. 



71 



In a hospital one nurse or assistant should be given 
the full charge of the instruments, being held re- 
sponsible for their proper sterilization and preserva- 
tion. In private practice the surgeon must give the 
instruments his personal attention ; and even in hospi- 
tals he will do well to watch closely the assistant to 
whom the j are intrusted, in order to be sure that the 
constant careful attention which is absolutely neces- 
sary is being paid to them. 

It is important to write out lists of the instruments 
that are used in the different operations and to keep 
them where they can be easily consulted on each 
operation day, so that none which will be needed 
will be forgotten. These lists should be divided into 
two parts, the first containing the instruments which 
are sure to be required, the second those that may 
possibly be needed under certain circumstances, and 
which should therefore be prepared, although they 
may be set aside until they are called for. A little 
foresight and extra trouble will often be repaid in cases 
of emergency. 

Instruments for an Abdominal Section. 



Aspirator. 

Cautery (Paquelin). 

Forceps, long dressing 1 

long haemostatic 6 

medium haemostatic .... 3 

small haemostatic 3 

bullet 1 

rat-tooth 2 

Needles, curved, very large (No. 1) 1 

large (No. 4) 2 



Needles, intermediate (No. 3) . . 2 

small (No. 2) 2 

intestinal (No. 1) .... 1 
transfixion, right curved . 1 

left curved 1 

Needle-holder 1 

Retractors, large 2 pairs. 

next size smaller ... 2 " 

Scalpels 2 

Scissors, long 1 pair. 



72 



ASEPTIC SURGICAL TECHNIQUE. 

PLATE VI. 
Fig. 1. 




^-~ 



Needle-holder. 
Fig. 2. 



" SSvTZ, KSON5. FhTa^J 



Vaginal packer. (Kelly.) 
Fig. 3. 




Retractor. (Robb.) 
Fig. 4. 




CXSKTZJ^SOWB 



Scalpels. 



INSTRUMENT LISTS 



73 



Instruments for an Abdominal Section. — Continued. 



Scissors, short 1 pair. 

Sound, uterine 1 

Speculum, Sims' 1 



Sponge-holders 4 pairs. 

Tenaculum, straight .... 1 



Additional for Ovarian Cysts. 



Trocars, large and small. 
Rubber tubing. 



Two Nelaton's forceps. 



Additional for Extra-Uterine Pregnancy, Hysteromyomectomy, or 
Supra- Vaginal Hysterectomy, and Vaginal or Infra- Vaginal Hys- 
terectomy. 

One dozen pairs of long haemostatic forceps. 

Two Museux forceps for seizing tumors. 

Glass- Ware. 

Catheters 2 

Flask, sterilized, to receive fluid (contents of cysts, etc.) for examination 1 

Nozzles (for irrigation) 2 



Instruments for 

Catheter, glass 

Curette, small 

Martin's 

Forceps, long dissecting .... 

short dissecting 

long haemostatic 

medium haemostatic .... 

small haemostatic 

bullet 

Pean's curved 

Pean's straight 

Needles, curved, large 

small 

medium 

transfixion, right-curved . . 
straight 



Vaginal Hysterectomy. 



Needle-holders 2 

Retractors, large 

next size smaller . . . 

small size 

Scalpels 

Scissors, long 

sharp-pointed 

Speculum, Sims' 

Simon's, with handles 
and four blades . . . 

Sound, uterine 

Sponge-holders 

Tenaculum, straight .... 

blunt 

round, sharp 



pair. 



74 



ASEPTIC SURGICAL TECHNIQUE. 



PLATE VII. 
Fig. 1. 




Scissors. 




Uterine sound 



Fig. 3. 




Sims' speculum. 



INSTRUMENTS. 



75 



PLATE VIII. 
Fig. 1. 




Trivalve speculum. 



Fig. 2. 




Sponge-holder. 



Fig. 3. 



Corrugated tenaculum. (Kelly.) 



76 



ASEPTIC SURGICAL TECHNIQUE. 



PLATE IX. 



Fig. 1. 




Fig. 2. 




Trocar. 



Nelaton's forceps. 



ASEPTIC SURGICAL TECHNIQUE. 



77 



Instruments for Perineorrhaphy. 



Catheters, glass, small 1 

large 1 

Forceps, haemostatic, long ... 2 

intermediate 2 

small ... 12 

long dressing 1 

bullet 2 

rat-tooth, small 2 

Needles as for abdominal sections 

(omitting the largest). 

Needle-holders 2 



Retractor, small 1 

intermediate 1 

Scalpels 2 

Scissors, right-angled ... 1 pair. 

left-angled 1 " 

straight-pointed ... 1 " 
Shot-compressor and shot. 

Sound, uterine 1 

Tenaculum, straight ... 1 

Tenacula, curved 2 



Instruments for Trachelorrhaphy. 



Catheter, glass 2 

Curette, Sims' 1 

sharp 1 

Martin's blunt, double ... 1 

Dilators, different sizes 3 

Forceps, haemostatic, two of each 

size 6 

long dressing 1 

rat-tooth dressing 2 

bullet 2 

Needles, assorted sizes 8 



Needle-holders 2 

Retractor, small 

intermediate ....... 

Scalpels 

Scissors, straight 

Shot-compressor and shot. 

Sound, uterine 

Speculum, Sims' small 

Simon's, with handles and 

four blades 

Tenaculum, straight 



Instruments for Dilatation of Cervix and Curetting of Uterus. 



Catheters, glass 2 

Catheter, irrigating two-way, small 1 

Curette, Sims' sharp 1 

Martin's blunt, double ... 1 
Dilators, three sizes, Goodell-Ellin- 
ger. 
Hegar's, three sizes. 



Forceps, bullet 2 

long dressing 1 

rat-tooth 1 

Sound, uterine 1 

Speculum, Sims' small 1 

Simon's, with handles and 

four blades 1 

Tenaculum, straight 1 



78 



INSTRUMENTS. 



Instruments for Colporrhaphy. 



Glass catheters 2 

Uterine sound 1 

Bullet forceps 2 

Tenacula, straight and curved . . 2 

Scalpels 2 

Scissors, straight 1 

Emmet's right and left curved 2 

Dissecting forceps, rat-toothed . 2 

Haemostatic forceps, small .... 6 



Long dressing forceps 1 

Needles, full curve, three sizes . . 6 

Needle-holders 2 

Retractors, two pairs of small and 

intermediate size 4 

Speculum, Simon's 1 

Sims' 1 

Shot, perforated 6 

" -compressor 1 



Instruments for Vaginal Myomectomy. 



Glass catheters 2 

Uterine sound 1 

Bullet forceps 2 

Tenacula, straight and curved . . 2 

Scalpels 2 

Scissors, straight 1 

curved on the flat 1 

Curettes, Martin's dull and sharp . 2 

Dilators, Hegar's 4 

Goodell-Ellinger 3 

Museux volsellum forceps .... 2 



Sponge-holders 4 

Speculum, Sims' I 

Simon's, with two handles 

and four blades 1 

Retractors, three sizes . . . pairs 3 

Needles, three sizes 6 

Needle-holders 2 

Long dressing forceps 1 

Dissecting forceps, long 1 

Ecraseur 1 



Instruments for Nephrotomy and Nephrectomy. 



Scalpels 2 

Dissecting forceps, small rat- 
toothed 

long rat-toothed . . . 

Dressing forceps 

Haemostatic forceps, stout . . . 

long 

Retractors, Halsted's large . . 
Robb's large and medium 



sized 



Scissors, straight 2 



Scissors, curved on the flat ... 1 

Tenacula, straight 2 

Needles, three sizes 6 

Needle-holders 2 

Return-flow douche nozzle ... 1 

Transfixion or aneurism needle . 1 

Hysterectomy forceps, curved . . 2 

Searching needle 1 

Lithotomy forceps 1 

Rubber drainage-tube. 




Simon's speculum.. 



Fig. 2. 

Sims' curette (modified). 




Recamier's curette (modified). 



PLATE XI. 
Fig. 1. 




Modified Goodell-Ellinger dilator (smallest size). 



Fig. 2. 




Hegar's dilator. 



Pig. 3. 




Shot-eom pressor. 



Fig. 2. 



PLATE XII. 
Fig. 1, 




Two-way catheter. (Kelly.) 




Chlor of or m-bott le . 



Chloroform-inhaler. 



Fig. 4. 



Probe-pointed tenaculum. (Kelly.) 




Knife-bladed tenaculum. (Kelly. 



INSTRUMENT LISTS. 



79 



List for Abdominal Operations Outside of Hospital. 



Aspirator. 

Instruments in bags. 
Basins for instruments. 
Cautery (Paquelin). 
Coats for doctors and nurses. 
Solutions :* five hundred cubic centi- 
metres bichloride solution (1 
to 20). 
five hundred cubic centimetres 

crude carbolic acid, 
normal salt. 
Crystals of permanganate of potas- 
sium and oxalic acid. 
Soap and two brushes. 
Rubber sheets and ovariotomy pad. 
Sterilized towels. 
Ether and cone. 
Chloroform and inhaler. 



Hypodermic syringe. 
Brandy. 

Strychnine tablets (^j grain). 
Rubber tubing. 
Six sponges (gauze, 24). 
Silk ligatures, four sizes (three tubes). 
Catgut ligatures, three or four sizes. 
Silkworm-gut, two sizes. 
Scultetus bandage. 
Safety-pins. 
Sterilized gauze. 
Strips of gauze for dressing. 
Celloidin. 
Sterilized cotton. 
Iodoform and boric acid powder. 
Glass graduate or agate ware 
pitcher. 



List for Perineal and other Minor Operations. 



Instruments. 
Leg-holder. 
Ligatures. 
Sterilized stockings. 
Perineal pad. 



Douche bag. 

Dressings. 

Bandages. 



Instruments and Materials for making Applications. 



One Sims speculum, small. 

One pair of bullet-forceps. 

One pair of long dressing-forceps. 

One pair of straight-pointed scissors. 

One vaginal packer. 

One aluminium applicator. 

Vaseline. 



Churchill's tincture of iodine. 
Cotton pledgets. 
Two basins. 
Fifty-per-cent. boro-glycerin 

tion. 
Tampons of cotton and wool. 



solu- 



* Carbolic acid, tablets of bichloride of mercury and of sodium chloride for 
solutions. 



80 ASEPTIC SURGICAL TECHNIQUE. 



Instruments for Catheterization of the Ureter. 

Applicator 1 

Catheters, glass 2 

ureteral 3 

Dilators, ureteral, 8-10 mm. ... 3 
Endoscopes with calibrators, 8- 

10 mm 3 



Forceps, long, mouse-tooth . 1 pair* 

Head mirror 1 

Searcher, ureteral .... 1 

Syringe 1 



The problem of discovering a simple and effectual 
way of sterilizing metal instruments has been a diffi- 
cult one. Many methods have been employed, but 
none is more satisfactory than that introduced by 
Schimmelbusch, to be described presently. The ex- 
posure of the instruments to the flame of a Bunsen 
burner or spirit lamp is an effectual way of steril- 
izing them, but the method has many disadvantages. 
The time required and the danger of overheating 
and blackening the instruments-, besides at the same 
time of dulling them, make it useless except on rare 
occasions or when, perhaps, a single scalpel or needle 
is required for immediate use. The hot-air sterilizers, 
which have been introduced especially for the sterili- 
zation of metal instruments, have been found to be 
unsatisfactory for this purpose. To make sure that 
the instruments are completely sterile, it is necessary 
to keep them in the hot-air sterilizer at a temperature 
of from 150° to 180° C. (300°-350° F.) for at least 
two hours. When one remembers that at least twenty 
minutes or a half an hour is necessary to bring the 
sterilizer to this temperature, and that some time 
will be required to allow the instruments to cool 



STERILIZATION OF INSTRUMENTS. SI 

down, it will be seen that more than two hours are 
required for the whole process. Of course this objec- 
tion may be obviated by following the recommenda- 
tion of Poupinel, who suggests that the instruments 
should be placed in tight metal boxes (Fig. 8) and ster- 
ilized on the day before the operation, being then 
allowed to remain in the boxes until just before they 

Fig. 8. 




Instruments in metal box. 

are needed. But in any case the inconvenience is 
great, and still another serious objection is found in 
the fact that, in spite of the greatest care, instruments 
thus treated will almost surely rust, even when the 
new " ventilated" disinfecting ovens are employed. 
Attempts to shorten the time required for sterilizing 
by hot air have given unfavorable results, and it has 
also been proved that exposure to a temperature above 
180° C. is deleterious to the temper of the steel, and 
affects the hardness and sharpness of the cutting in- 
struments. 

Some surgeons prefer to sterilize the instruments 
by means of steam, and employ the Arnold or some 

6 



82 ASEPTIC SURGICAL TECHNIQUE. 

other steam sterilizer. The instruments are put in 
bags made of " bird's-eye" or " towel" linen, which 
are then placed in the sterilizer and exposed to a tem- 
perature of 100° C. for an hour. The mouths of the 
bags are provided with draw-strings, by means of 
which they can be lifted from the sterilizer, and the 
instruments are turned out into the trays, which have 
been sterilized and which contain enough sterile water 
to cover them completely. If the instruments are al- 
lowed to dry in the sterilizer they are almost sure to 
rust or to become discolored. The time of steriliza- 
tion may be somewhat reduced if an autoclave be used, 
but all these methods of sterilization by steam are also 
open to the objection that they require too long a time 
and are apt to injure the instruments, 

From what has already been said with regard to dis- 
infection by chemical agents in Chapter II., it will be 
readily understood why, if only on the grounds of the 
injury done to the tissues, the method so much in 
vogue formerly, of simply placing the instruments in 
a solution of carbolic acid for a short time before the 
operation, must now be discarded. But besides this 
serious objection, solutions of carbolic acid which are 
concentrated enough to have any decided germicidal 
power may be injurious to those who handle the in- 
struments. In addition to the grave local lesions set 
up in the hands of susceptible individuals, instances 
of carboluria and of the severe general symptoms of 
carbolic-acid poisoning have more than once been 
noted simply from the effects of handling instruments 



STERILIZATION OF INSTRUMENTS. §3 

kept soaking in the solutions during prolonged opera- 
tions. 

Instead, therefore, of employing dry heat or steam, 
or trusting to chemical solutions, surgeons during the 
past few years have had recourse to the boiling of the 
instruments in water and other fluids. The French 
writers have recommended boiling glycerin and oil of 
various kinds, but the use of these need not be dis- 
cussed here, since in simple boiling water we have an 
efficient and speedy disinfectant for instruments. Five 
minutes suffice for complete sterilization. The most 
serious objection to the use of plain water, which has 
been very warmly recommended by Dandrohn, Re- 
dard, and others, lies in the serious damage done to 
the instruments. If they are placed in ordinary cold 
water and boiled, they will often be found to be 
studded with spots or even covered thickly with rust. 
The danger can to a great extent be avoided if the 
water be boiled for some time before the instruments 
are placed in it, and the addition of some alkali to the 
boiling water is a sure preventive, the one best suited 
for the purpose, as shown by Schimmelbusch, being 
ordinary washing-soda (sodium carbonate). 

The method employed by Schimmelbusch for ster- 
ilizing instruments is by far the most convenient and 
effective for general employment, and has been used 
for some time in many operating-rooms with uni- 
versally satisfactory results. It was first introduced 
into von Bergmann's clinic in Berlin, and, while free 
from objection from a bacteriological stand-point, has 



84 ASEPTIC SURGICAL TECHNIQUE. 

the additional advantages of requiring very little time, 
of being inexpensive, and of entirely doing away with 
the danger of rust. Soda also adds to the disinfectant 
power of the boiling water. Repeated experiments 
made to test the efficacy of the method have shown 
that a boiling one-per-cent. soda solution kills all 
known pyogenic organisms in from two to three 
seconds, while anthrax spores are all destroyed after 
an exposure of two minutes. The procedure is as 
follows : the instruments (which have been thoroughly 
cleansed after the preceding operation) are boiled for 
five minutes in a one-per-cent. solution of carbonate 
of sodium. Any vessel can be made to serve for this 
purpose if one is operating in a private house, but 
in hospitals and operating-rooms it is convenient to 
have a specially-constructed apparatus made of cop- 
per, agate-ware, or nickel. This consists of an oblong 
boiler fitted with a cover. The heat beneath can be 
supplied by Bunsen burners ("wreaths") or by a 
spirit-lamp; or where these cannot be obtained, the 
boiler can be set directly upon a stove. The size of 
the boiler required will depend, of course, upon the 
amount of work to be done. In hospitals one of large 
size will be necessary, but in private practice or in 
small operating-rooms a boiler twenty to forty centi- 
metres long (8-16 inches), fifteen to twenty centimetres 
wide (5J-8 inches), and ten to twelve centimeters (4- 
4J inches) deep will answer every purpose (Fig. 9). 
In making the soda solution, one soon learns how 
much, approximately, of the dry soda to add to a given 



STERILIZATION OF INSTRUMENTS. 



85 



amount of water without actually weighing it ; but to 
save time and insure accuracy, a concentrated solu- 
tion of known strength may be kept ready, so that by 
simply diluting it a one-per-cent. solution may be made 



Fig. 9. 




Boiler for soda solution. 

whenever it is required. In order to facilitate the in- 
troduction and removal of the instruments, a flat wire 
basket which fits into the boiler will be found very 
convenient. (Fig. 10.) After they have been boiled 
for five minutes the wire basket containing the instru- 
ments is removed, and the latter are turned out into 
sterilized trays which contain sufficient warm steril- 
ized water to cover them. Instead of simple water, 
a cold (previously boiled) one-per-cent. soda solution 
may be used in the trays, or a solution which contains 
one per cent, of soda and one per cent, of carbolic 
acid. The addition of the latter would seem, how- 



86 



ASEPTIC SURGICAL TECHNIQUE. 



ever, to be entirely unnecessary. Between operations 
which follow one another in rapid succession, or if 
some of them by chance have come in contact with 
non-sterile material during an operation, the instru- 
ments may, after being carefully washed in cold water, 
be quickly resterilized in the boiling soda solution. 

Fro. 10. 




Instrument sterilizer. 



The procedure should be actually timed by a watch 
kept hanging up in the operating-room. 

The most satisfactory vessels to keep the instruments 
in at the time of the operation are trays made of thick 
glass (Plate XIII., Fig. 1), which are easily sterilized. 
On account of the cost, however, great care must be 
exercised while sterilizing them or washing them 



PLATE XIII. 




Fig. 1. — Glass dishes. 




Fig. 2. — Sterilized towels in three-per-cent. carbolic solution. 

Fig. 3. — Sterile cotton in glass jar. 

Fig. 4. — Sponges in three-per-cent. carbolic acid solution. 




Fig. 5. — Sterilized tampons of lamb's wool 

and absorbent cotton in glass jar. 
Fig. 6. — Sterilized gauze in glass jar. 
Fig. 7. — Ligatures in glass jar. 



Fig. 8. — Gauze drains. 



STERILIZATION OF DISHES. 87 

in hot water, else they are liable to be broken. 
Glass dishes are best sterilized by means of dry heat, 
but besides the length of time required and the risk of 
breakage, the bulkiness of the glass-ware which is used 
renders the procedure very inconvenient in practice. 
The smooth surface of glass dishes, which can easily 
be kept perfectly clean, makes it possible to render 
them sterile by mechanical means supplemented by 
sufficiently strong solutions of bichloride of mercury. 
They are first washed thoroughly with water and then 
filled to the brim with an aqueous solution of bichloride 
of mercury (one to five hundred), which is allowed to 
remain in them for an hour before they are needed 
for use. Just before the operation they are finally 
rinsed out well with sterile water and after being 
placed upon the table are filled with enough sterilized 
water or salt solution to cover the instruments. If 
they are required for a second operation following 
closely upon the first, they may be cleansed by rins- 
ing them out with cold water to which hot water is 
cautiously added, then with a one to five-hundred bi- 
chloride solution, and lastly with sterilized salt solution. 
To clean them before putting them away after the oper- 
ations are over for the day, they are washed out thor- 
oughly with soap and warm water and are then turned 
upside down and allowed to drain until they are per- 
fectly dry. 

If glass dishes cannot be obtained, trays made 
of hard rubber, agate-ware, or porcelain may be 
substituted for them. They can be sterilized in the 



88 



ASEPTIC SURGICAL TECHNIQUE. 



same way as the glass dishes. (Figs. 11, 12, and 
13.) 

The instruments which have been used should first 
be washed in cold water, in order to remove all pus, 
blood, or tissue-particles. They are next immersed in 
hot soda solution and thoroughly scrubbed with soap 

Fig. 11. 




and brush. After being rinsed off they are wiped dry 
with a soft towel and polished with a piece of chamois 
skin. Finally, they are boiled for iive minutes in a 
one-per-cent. soda solution and carefully wiped dry, 

Fig. 12. 




after which they may be put away in their proper 
places in the instrument case. Instruments thus care- 
fully and regularly treated will never rust and will 
always be clean and bright. 



CARE OF INSTRUMENTS. 



89 



In all these manipulations instruments with cutting 
edges should be handled with particular care, in order 
that they may not be dulled. The edges should not 
be allowed to come in contact with hard surfaces, as 
they would do if they were roughly handled and care- 
lessly dumped into the trays. Great care is also neces- 
sary when wiping off the blades. In those instruments 
the parts of which are connected by means of the 
French lock it is especially important that no moisture 
should be allowed to remain in the joints, and the 

Fig. 13. 




Robb's aseptic ligature tray. 



numbers on the several parts should be carefully noted, 
so that those which correspond maybe joined together. 
Neglect of this simple rule will soon ruin the instru- 
ments. Force should never be exercised in adjusting 
them, as the pivots are delicate and the slightest rough- 
ness will prevent their accurate apposition, so that after 
a short time the joints will become so loose as to be 
quite useless. 
The instrument cases are described in Chapter XL 
"When a surgeon wishes to carry sterilized instru- 



90 ASEPTIC SURGICAL TECHNIQUE. 

merits with him to avoid the necessity of sterilizing them 
at a private house, they should be boiled in the one-per- 
cent, soda solution, wiped with a sterilized towel, and 
put in sterilized bags, which are then placed in tight 
metal boxes made for the purpose, the latter having been 
previously sterilized by dry heat ; the boxes are to be 
left unopened until the time of the operation. It is 
probably safe, however, to carry the sterilized instru- 
ments in the sterilized bags with the other things in 
the telescope valise, omitting the use of the metal box. 
The ordinary case or loose bag formerly employed for 
carrying instruments should, of course, no longer be 
used. It will, as a rule, be found more convenient, 
even for operations in private houses, to carry a small 
apparatus for sterilizing instruments, but, as a matter 
of fact, we can find in almost any house a vessel in 
which they can be boiled. 



CHAPTER VI. 

ASEPTIC SUTURES, LIGATURES, AND CARRIERS — SUTURE MATE- 
RIALS — STERILIZATION AND PRESERVATION OF THE VARIOUS 
KINDS. 

We have a variety of materials from which to select 
our sutures and ligatures. The substances commonly 
employed are the cable twist silk, silkworm-gut, cat- 
gut, silver wire, kangaroo tendon, and horse-hair ; and 
of these silk, silkworm-gut, and catgut are most fre- 
quently used. No one suture material will suffice for 
all purposes, although silk can be made available for 
the majority of cases. Whatever we use, the main 
point is that it shall be sterile, and, as we shall see 
later, we may have a material which at first sight ap- 
pears in every way adapted for our purpose, and 
yet presents such apparently insuperable difficulties 
in the way of rendering it sterile that, in the eyes 
of the aseptic surgeon, the risks accompanying its 
use may more than overbalance its other advantages. 
The material must also be smooth and pliable but 
not brittle, and it is but natural that, cceteris pari- 
bus, we should choose something not too costly and 
which is easily obtainable. If I were asked to state 
my preference in regard to the materials in ordinary 
use, I would, on the ground of the bacteriological ex- 
periments made by Dr. Ghriskey and myself, place 

91 



92 ASEPTIC SURGICAL TECHNIQUE. 

them in the following order; (1) silkworm-gut, fine 
and coarse ; (2) surgeon's cable twist silk, Nos. 1, 2, 3, 
4, and 5 ; (3) silver wire, fine and coarse ; (4) catgut, 
sizes a, b, c, d, and e. Since, however, silk is the 
material most commonly used, we will take it up 
first. 

When using the surgeon's cable twist, five sizes are 
to be kept in stock: No. 1 (fine) is very necessary 
when carriers are to be employed. (Fig. 14.) The car- 



Fig. 14. 




Needle armed with a carrier. 



rier is of the greatest convenience, as it does away with 
the necessity of having a large number of needles 
and also facilitates quickness in the performance of 
an operation. It consists of a piece of silk fifty centi- 
metres (nineteen inches) in length, and is prepared in 
the following way. The surgeon passes the two ends 
through the eye of the needle from opposite directions. 
An assistant then holds the needle, or it may be allowed 
to hang down over the side of the hand while the 
two ends are tied snugly in a knot; slight traction 
being made on the loop thus formed, the knot is se- 
curely fixed in place immediately behind the eye of 
the needle. As the operator passes the needle through 
the tissues, each suture, as it is to be introduced, is 



PREPARATION OF SUTURES. 93 

threaded by an assistant through the loop of the car- 
rier, and is thus drawn into its place. One has not 
to employ this method long for the introduction of in- 
terrupted or continuous sutures in order to appreciate 
its advantages. 

The next size of silk sutures (No. 2) is used for super- 
ficial sutures which are to bring the skin and subcu- 
taneous tissues in apposition. Sizes Eos. 3 and 4 are 
employed for deep sutures which are to approximate 
muscular tissues. Size No. 5 (heavy) is used in the 
ligation of pedicles or whenever a heavy ligature is 
necessary for any other purpose. Instead of Noq. 3, 
4, and 5 of the surgeon's cable twist, we have found 
that the best quality of gum silk will answer every 
purpose. The ligatures are wound on glass reels 
(Fig. 15), and it will be found that by the adoption of 
a routine method of arranging them much confusion 
will be avoided. The glass reels are placed in " ig- 
nition test-tubes" (Figs. 16 and 17), a piece of non- 
absorbent cotton being placed in the bottom of the 
tube upon which the reels rest. Each tube for an 
abdominal operation should contain four reels, one of 
the heavy silk, one of silk of intermediate weight, one 
of No. 2, and one of the fine silk for the carrier. The 
first reel holds four heavy ligatures, each one metre 
(thirty-nine inches) in length. These ligatures may be 
wound separately, but it is generally better to wind 
them together, as they can then be more conveniently 
removed from the reel. On the second reel should 
be wound ten " intermediate" or deep ligatures, each 



94 



ASEPTIC SURGICAL TECHNIQUE. 
Fig. 15. Fig. 17. 




Glass reels for ligatures. 
Fig. 16. 



i J ~± 



I 




Ignition test-tubes with ligatures on reels. 



PREPARATION OF SUTURES. 95 

forty centimetres (sixteen inches) in length. The third 
reel is for ten superficial ligatures, each forty centi- 
metres in length; the fourth holds eight fine ligatures 
(for carriers), each fifty centimetres (nineteen inches) 
in length. This number of carriers will be necessary, 
as it is important to have one for each of the several 
needles of different sizes which are likely to be re- 
quired in the course of the operation. After the silk 
has been cut into the required lengths, the strands are 
bunched into fours and wound together (not sepa- 
rately) on the glass reels. The full reels are placed 
in the heavy glass tubes, the mouth of each tube being 
plugged with ordinary cotton batting. The empty 
tubes, plugged with cotton, should have been pre- 
viously sterilized in the hot-air oven. Absorbent 
cotton should not be used for this plug, as it will take 
up moisture from the air, and fungi will be much more 
likely to grow through it. The tubes with the ligatures 
in them are to be sterilized in the Arnold steam steril- 
izer for one hour the first day and for half an hour on 
each of the two succeeding days, or in the autoclave 
on two successive days for half an hour each time. It 
is, perhaps, not absolutely necessary to sterilize them 
more than twice, but it is safer to adopt the routine 
method of sterilizing on three successive days. "When 
the ligatures have thus been rendered aseptic they 
will remain so indefinitely if the tubes are kept well 
plugged and in a dry place. Instead of the arrange- 
ment mentioned above, the different sizes of ligatures 
may be kept in separate tubes, and each tube will then 



96 ASEPTIC SURGICAL TECHNIQUE. 

have to be opened only when the particular size of 
suture which it contains is required. If the plug is 
carefully held by its outer surface, and is replaced when 
one reel is removed, the others, if separated by small 
plugs, will not be contaminated, provided that we are 
careful either to allow the reels which we require to 
roll out of the tube into the solution prepared for 
them, or else (and this is perhaps the safer way) to re- 
move them from the tube by means of a pair of steril- 
ized forceps. If, however, there should be the least 
suspicion that the ligatures on the remaining reels 

Fig. 18. 




Sterilized catgut in sealed glass tubes. 

have become contaminated during this manipulation, 
the tube with its contents must again be placed in the 
sterilizer or autoclave for an hour. The tubes can be 
kept in glass jars like those employed by confectioners, 
each jar as well as each tube being provided with a 
label bearing the date of sterilization. Plate XIII, 
Fig. 7. Some surgeons prefer to resterilize their silk 
ligatures immediately before every operation. This 
can easily be done by placing the tubes in the Arnold 
sterilizer, or the reels may be taken from the tubes and 
boiled with the instruments in a one-per-cent. soda 
solution. Silk ligatures will not, however, bear steam- 



PREPARATION OF SUTURES. 97 

ing many times, as the procedure renders them brittle. 
Ligatures kept on reels with the rods coming out 
through openings in the containing glass jars are very 
objectionable,, as such packages are certain to become 
contaminated. Ligatures kept in antiseptic oils and 
fluids are even worse. 

A linen thread, called " Pagenstecker " after its 
inventor, is a very useful non-absorbable suture mate- 
rial. It is much stronger than silk, if strands of equal 
diameter are compared. It is now much used in intes- 
tinal work, for closing the fascia layers of the abdominal 
wall, and indeed in all situations where a very strong 
suture of small volume is desired. It comes in skeins 
of several sizes, No. 2 and No. 1 being the most 
widely used. It may be rolled upon glass reels and 
sterilized in glass tubes, exactly as in the case of silk. 

Silkworm-gut has a smooth surface, compact, and 
free from interstices so that it can remain in position 
longer than silk without injury to the tissues. This 
is an advantage in wounds like that of a perine- 
orrhaphy, whenever we wish the sutures to remain 
more than a few days. Silkworm-gut is easily intro- 
duced and moulds itself readily to any desired position 
in a wound. When properly applied, it does not pro- 
duce the same constriction of the tissues as either silk 
or silver wire, but acts as a supporting splint. The 
sutures can be removed very easily when desired, and 
experiments have shown that silkworm-gut resists the 
invasion of bacteria much better than silk or catgut 
which has been left in for the same length of time. It is 

7 



98 ASEPTIC SURGICAL TECHNIQUE. 

best employed in two sizes, the coarse and the fine, and 
may be bought in bundles of one hundred strands, at a 
cost of seventy-five cents a bundle. Silkworm-gut is 
sometimes stained red, but this procedure is not neces- 
sary, although the ligature is in this way rendered 
more easily visible. In preparing it for use, the 
twisted ends of the strands having been cut off, a dozen 
ligatures, folded once, are placed lengthwise in each 
of the glass tubes in which they are to be kept. 
The methods which we described for the sterilization 
and preservation of silk sutures will apply equally well 
to sutures of silkworm-gut. They should be placed in 
a sterilized tray containing sterile water or salt solu- 
tion half an hour before the operation. This renders 
them more pliable, and they are not so likely to break 
as when they are used perfectly dry. Any silkworm- 
gut remaining after an operation can be rinsed off and 
resterilized for another time by repeating the process 
described above. As a rule, it is better not to make 
a complete knot when employing silkworm-gut, but 
to use instead only the first stroke of the surgeon's 
knot, which will hold quite well. The advantage of 
this is that the threads lie flat, the sutures can after- 
wards be tightened or loosened at will, and the parts 
are kept in perfect apposition without any constriction 
of the tissues. 

Silver wire is now frequently used, as experiments 
tend to show that the metal has a definite antiseptic 
effect in the tissues. It may be used subcutaneously or 
as a deep suture. Otherwise it is less desirable than 



CATGUT. 99 

silkworm gut, as it is more expensive and is more apt 
to injure the tissues. It can be bought in different 
sizes, and generally comes wound on spools. It can be 
sterilized by steam heat, by means of dry heat, or by 
boiling in the one-per-cent. solution of soda. 

Catgut appeared to be an almost ideal material for 
sutures, but, unfortunately, we had no thoroughly re- 
liable method of rendering it absolutely sterile without 
at the same time making it so weak as to unfit it for 
our purpose. When properly handled, it supports the 
tissues for a sufficient length of time to allow of a 
thorough approximation of the parts, and after it has 
served its purpose the suture is absorbed. Just as 
soon, then, as we found a reliable method for steril- 
izing catgut which did not at the same time destroy 
its other necessary properties, we acquired a ligature 
material of the highest value. Different specimens 
of catgut vary greatly, and, although some of the 
methods of sterilization which are advocated are per- 
haps effective in the majority of instances, it not in- 
frequently happens that a few of the strands are not 
rendered sterile, and many cases of suppuration or 
death following operations have been directly traceable 
to the use of catgut ligatures. 

There are several methods now adopted for steriliza- 
tion of catgut, but I shall only refer to a few of those 
most commonly employed. 

(1) Cumol Method. — The strands of catgut are rolled 
separately in rings and heated gradually in a hot-air 
oven. After the temperature has reached 70° C, it is 



100 ASEPTIC SURGICAL TECHNIQUE. 

maintained at this point, and the catgut is allowed to 
remain in the oven for about two hours. Exposure to 
dry heat of 100° C. or over renders catgut brittle. 

The rings are then transferred to a glass vessel con- 
taining cumol, which is heated in a sand-bath to 155°- 
165° C. for one hour. 

An ordinary enamelled saucepan can be used for 
holding the sand. The beaker containing the cumol 
is surrounded for two-thirds of the way up the sides 
with sand in order to insure the rapid and regular dis- 
tribution of the heat. 

The top of the beaker should be covered with a piece 
of wire gauze, since, although cumol is not explosive, 
it ignites if it is brought in direct contact with the 
flame. 

Two Bunsen burners may be employed at first, and 
as soon as the thermometer shows '155° C. one may be 
withdrawn, after which a temperature of 155°-165° C. 
can be easily maintained for one hour. Kronig holds 
that it is impossible to do the catgut harm by over- 
heating, but other authorities are of the opinion that 
exposure to a temperature of over 165° C. for any 
length of time renders the strands brittle. 

The catgut is next transferred to a sterilized vessel 
containing chemically pure benzine and allowed to 
remain for three hours, being afterwards preserved in 
absolute alcohol. 

If preferred, however, it may be kept in the benzine 
till shortly before it is required for use, in which case 
it is only necessary to allow it to lie on a sterilized towel 



PREPARATION OF SUTURES. 101 

for an hour, in order that the benzine may have time 
to completely evaporate. 

By this method we can obtain a suture material 
which is not only sterile but is not impregnated with 
any irritating substance. 

Kronig's method of catgut sterilization, modified by 
Clark and Miller (The Johns Hopkins Hospital Bulle- 
tin, No. 114, 1900), has proved to be perfect as regards 
its germicidal properties, and when properly carried 
out gives a strong, pliable catgut. In order to preserve 
the catgut in the tissues for a longer period of time than 
six to ten days, Miller has made use of a combination 
of formalin and cumol. He suggests soaking the catgut 
in a four-per-cent. formaldehyde or a ten-per-cent. for- 
malin solution for ten hours; it is then washed for 
several hours in running water, dried, and sterilized 
by the cumol method. Miller has found that this cat- 
gut will last from fourteen to eighteen days. If soaked 
too long, or if the formalin is not thoroughly washed 
out, the catgut loses its strength. Catgut prepared in 
this way, as Miller has conclusively demonstrated, is 
free from bacteria. 

(2) Hofmeister's Method. — The catgut is wound very 
tightly on glass plates and immersed in a two to four 
per cent, solution of formalin for from twelve to forty- 
eight hours. It is then washed in flowing water for at 
least twelve hours. It is then boiled in water for from 
ten to thirty minutes, after which it is placed in a 
mixture of absolute alcohol with five-per-cent. glycerin 
and one per cent, of bichloride of mercury, and left 



102 ASEPTIC SURGICAL TECENIQUE. 

there until it is to be used, when it is washed off in 
sterile water or sterile salt solution. 

Senn has substituted ten-per-cent. iodoform for the 
bichloride of mercury, and finds the suture just as 
sterile and less irritating. 

(3) Claudius 1 Method. — Commercial raw catgut, with- 
out any preliminary preparation, is wound on glass 
plates and immersed in a one-per-cent. aqueous solu- 
tion of iodine and potassium iodide, in which it is left 
for at least seven days. When it is to be used it is 
washed off in a three-per-cent. carbolic solution or in 
an indifferent sterile solution. 

(4) A fourth method is as follows : Six strands of 
catgut of different sizes, each forty centimetres (sixteen 
inches) long, are wound on a glass reel. A number of 
these reels are placed in a bottle of ninety -five-per-cent. 
alcohol, care being taken that the catgut is completely 
covered, some slight allowance also being made for 
evaporation. The mouth having been plugged with 
cotton, the bottle is placed in a water-bath, which is 
heated until the alcohol boils. The heating is repeated 
on three successive days. The stopper is then put in, 
being protected with paraffine or rubber protective, 
unless the ligatures are required for immediate use. 
When required, some of the reels may be taken from 
the bottle by means of a pair of sterilized forceps. If 
it is thought preferable the strands on each reel may 
be all of the same calibre, in which case it will be 
advisable to have a complete series of the reels in the 
same bottle. We have been using with some satisfac- 



PREPARATION OF SUTURES. 103 

tion Kiliani's dry catgut in different sizes; also St. 
John Levan's and Van Horn's chromicized catgut. It 
should be said, however, that in using the large size of 
the chromicized gut we have found that the suture 
sometimes does not become absorbed, but gradually 

Fig. 18A. 



Tube of sterilized catgut. 

works its way to the surface and is then discharged. 
When applying ligatures it is of the greatest im- 
portance, as has been previously pointed out, to avoid 
any undue constriction of the tissues which might lead 
to obstruction of the circulation and diminish the 
normal resistance of the parts. The manipulation of 
the sutures and ligatures is too often a weak point in the 
technique of surgeons. The ligatures are sometimes 
cut into lengths just before the operation, and the 
ends are not infrequently allowed to hang down over 
the edge of the dish in which they are arranged. 
Sometimes they are brought in contact with an un- 
sterilized object in being passed from the instrument- 
table to the operator, and even after they have reached 
his hands the ligatures are still often in great danger 
of becoming infected, so that it may be truthfully said 
that where a large number are employed during an 
operation it is a wonder that they can all be kept 
aseptic. 



CHAPTEE VII. 

STERILIZED DRESSINGS — COTTON — GAUZES — BANDAGES — TAM- 
PONS — SPONGES. 

The early surgeons, and particularly those in hos- 
pital practice, laid great stress upon the dexterous 
application of many complicated bandages and dress- 
ings, and looked with some pardonable pride upon 
their parallels and angles, their reverses from straight 
lines, and the even, smooth dressings which were then 
considered an essential part of a good surgical tech- 
nique. As a matter of fact, the application of the 
non-sterile dressing of those days often did more harm 
than good, and we can hardly be surprised that many 
surgeons were led to believe that they could obtain 
better results from treating wounds by exposure to the 
air than by covering them with gauze and bandages, — 
results which we are less likely to question, since it 
has been proved how much greater are the dangers of 
infection by contact than those of infection from the 
air. The various efforts to obtain a more satisfactory 
method of dressing wounds need not be discussed here. 
Many of us still remember the treatment by the earth 
dressing, so lauded by Addinell Hewson. In studying 
the statistics of wounds which have been treated in 
this way, one is struck by the number of cases in which 
the patients subsequently died of lockjaw, and to-day 
104 



DRESSINGS. 105 

a surgeon would be thought very rash if he applied to 
the wound, without sterilization, a substance known to 
be the natural habitat of the tetanus-bacillus. 

The occlusive dressing has been much employed, 
and not without reason, inasmuch as it imitates more 
or less closely nature's own method. It has, indeed, 
its peculiar dangers, but, as will be shown later, it is 
often valuable in abdominal surgery. 

When a wound is not to be closed hermetically it is 
important to apply a dressing which, while being itself 
free from pathogenic bacteria, will prevent the access 
of micro-organisms from the outside, and at the same 
time will thoroughly absorb the secretions from the 
wound and prevent their subsequent decomposition. 
A great variety of substances have been recommended 
for their absorptive power, among them straw, bran, 
sand, ashes, tan-bark, tow, moss, wood, and sawdust, 
but no one of these is so useful or so generally applica- 
ble as cotton or gauze, which has been made capable of 
absorbing by the removal of all fatty substances from it. 
Good absorbent cotton can be bought for from forty to 
sixty dollars per hundred pounds. It is generally sold 
in rolls, each weighing one pound. Common cheese- 
cloth one yard wide costs about five dollars per hun- 
dred yards. For dressings it can be cut into lengths 
of two metres or of two yards and boiled for half an 
hour in a one-per-cent. solution of carbolic acid and 
soda, and then thoroughly rinsed in sterile water. The 
manufacturers have reaped bounteous harvests from 
the preparation of the so-called " antiseptic gauzes," 



106 ASEPTIC SURGICAL TECHNIQUE. 

made by saturating absorbent gauze with solutions of 
bichloride of mercury, carbolic acid, boric acid, salicylic 
acid, and cyanide of mercury and zinc. But now we 
know that all these methods of disinfection are ineffi- 
cient, and even if the materials are in a sterile condi- 
tion when packed by the manufacturers, the numerous 
subsequent handlings which they undergo before they 
come in contact with a wound would almost certainly 
lead to contamination. And if contamination can oc- 
cur so easily in this way, surely nothing need be said of 
the many instances in which " antiseptic gauze" has 
been thrown beneath the buggy seat, or at the bottom 
of not over-clean boxes or bags, to be placed a short 
time afterwards as a dressing upon a wound which it 
is meant to protect. 

The surgeon of to-day does not need to acquaint 
himself with these fancy preparations, except to learn 
to avoid them. Only in rare instances do we require 
a gauze impregnated with antiseptic substances (vide 
permanganate and iodoform gauze). It will generally 
be sufficient if we render our gauze and cotton free 
from pathogenic micro-organisms before applying them 
to wounds. The methods are not complicated, and 
surgeons are to be congratulated upon the immense 
simplification of dressings and of the ways of applying 
them which have been given to us through the recent 
advances in our knowledge of the different modes of 
infection and of the way in which it is to be avoided. 

Absorbent cotton, absorbent gauze, and bandages 
should be sterilized in the Arnold sterilizer or in the 



DRESSINGS. 107 

autoclave. Exposure for three-quarters of an hour to 
steam at 100° C. serves to render all these substances, 
if not packed or rolled together too tightly, absolutely 
sterile. It is best to sterilize the dressings shortly 
before each operation, and in large operating-rooms 
where several cases are operated upon daily, it is 
necessary to have several steam sterilizers. They are 
made in such numbers now that they are compara- 
tively inexpensive. But the question will be asked, 
How will the application of simple sterile gauze to 
wounds, in the absence of chemical substances, pre- 
vent the decomposition of the secretions from the 
wound which are taken up by the dressing ? The 
answer is so simple that it seems strange that we 
should only recently have appreciated it. One of the 
first requisites for the growth of micro-organisms is 
moisture. Bacteria do not multiply in dry substances. 
Good gauze and cotton permit of the constant evapo- 
ration of moisture from them, and so prevent bacterial 
growth. They do not remain damp long after being 
removed from the sterilizer, so that the dressings may 
be applied almost immediately after the sterilization 
has been completed. It is rather better, however, to 
place the dressings, which have been exposed to the 
steam, in a drying chamber for a short time before 
they are used. By using the autoclave this second 
step is rendered unnecessary. Dressings impregnated 
with antiseptics are useless, inasmuch as, in the first 
place, the presence of powerful antiseptics in sufficient 
concentration to have any germicidal effect would 



108 ASEPTIC SURGICAL TECHNIQUE. 

irritate the skin and the wound, and, secondly, all 
antiseptics are quite inactive in dry gauzes, when there 
is but little exudation, and therefore, in order to ob- 
tain any benefit from them, the dressing would have 
to be applied wet, whereas, as we have said, the dry- 
ness of the gauze constitutes in itself a great safe- 
guard. 

In order to have a stock of thoroughly dry and 
sterile cotton always on hand, the absorbent cotton 
may be cut into pieces of convenient size and securely 
wrapped in a towel or in a piece of gauze several layers 
thick. The bundle, securely but not too tightly fas- 
tened, is then sterilized in the Arnold sterilizer for 
from forty-five to sixty minutes, or in the autoclave for 
half an hour, and, after being allowed to dry in the air 
in a room where there is no dust, is kept until required 
for use in a closed glass jar or in a tin box. Plate 
XIII., Fig. 3. Sterilized gauze may be preserved in 
the same way. Plate XIII., Fig. 6. Before opening 
these sterilized packs the hands should either be disin- 
fected or covered with rubber gloves taken from a jar 
of five-per-cent. carbolic acid solution, or the pack may 
be removed with sterilized forceps. If any cotton or 
gauze is left over after the package has been opened, 
it may be again wrapped up and resterilized. 

In order to prevent contamination of the field of 
operation, it is necessary to surround it with sterilized 
gauze or towels. The latter are made of the ordinary 
towelling with plain hemmed edges. A supply of 
these, already sterilized, may be kept in a covered glass 



IODOFORM GAUZE. 109 

jar, dry or filled with a one to five hundred sublimate 
solution or a three-per-cent. carbolic acid solution, so 
that they are ready at all times. Plate XIII., Fig. 2. 
In the latter case, before being used, where they will 
come in contact directly or indirectly with the field of 
operation, they should first be rinsed in sterile water. 

Iodoform gauze is occasionally required for various 
purposes, and may be prepared in the following 
manner: plain gauze is cut into lengths of three 
metres (about three yards) each, and folded length- 
wise. For the iodoform mixture enough castile 
soap is mixed with two hundred cubic centimetres 
(3vi) of a one-per-cent. aqueous solution of carbolic 
acid to make good suds ; forty-five grammes (3xii) of 
powdered iodoform are then added, and the whole is 
thoroughly mixed. The quantities given above will be 
sufficient for the preparation of three metres of gauze. 
The gauze is immersed in the mixture, which must be 
well rubbed into the meshes. It is then rolled up, 
placed in a towel, sterilized, and kept in a sterile 
jar. In cutting off pieces of gauze for use, the 
hands must be sterilized or sterilized rubber gloves 
must be worn and a pair of sterilized scissors used. 
Such precautions as these are very important if we 
wish to prevent any possibility of contamination. 
When the iodoform gauze is to be used for dressing 
plastic cases, it is convenient to have it cut into strips 
ninety-four centimetres (36 inches) long and eight cen- 
timetres (3 inches) wide. Each strip is rolled up sep- 
arately, and several of these rolls are preserved in a 



HO ASEPTIC SURGICAL TECHNIQUE. 

sterilized glass jar. When required for use, they can 
be taken from the jar with sterilized forceps. 

Permanganate gauze is not infrequently used for 
dressings, and does a great deal to diminish the odor 
that is so objectionable in cases of cancer of the cervix 
and uterus, and elsewhere where there is any bad- 
smelling discharge. The ordinary gauze is cut into 
lengths of one metre (39 inches) each, folded length- 
wise, sterilized for one hour, and then saturated with 
a one-per-cent. aqueous solution of permanganate of 
potassium (ten grammes (160 grains) of the crystals of 
permanganate of potassium to one thousand cubic 
centimetres (33J ounces) of hot water). The gauze is 
cut and rolled in the same way as the iodoformized 
gauze, and should be preserved in a colored glass jar. 

Subiodide of bismuth may also be rubbed into gauze 
which is to be used for plastic cases. For three metres 
(3 yards 9 inches) of gauze a mixture of forty-five 
grammes (3xii) of pure subiodide of bismuth with 
one hundred and fifty cubic centimetres (£v) of water 
and thirty cubic centimeters (Si) of glycerin will be 
sufficient. 

Tampons of lamb's wool are especially useful when a 
non-absorbent material is desired. Such a tampon is 
very elastic and serves excellently as a support. A 
piece of wool thirty centimetres long and three cen- 
timeters wide (11 inches by 1 inch) is twisted over 
three fingers so as to form a loop. Round it at this 
point a piece of stout linen thread is tied, the ends 
being left free. The tampons are then sterilized in 



BANDAGES. 



Ill 



the Arnold steam sterilizer or autoclave and kept in 
aseptic glass jars. 

Tampons of absorbent cotton are made in very much 
the same way. The cotton, as it is taken from the 
roll, is cut into pieces measuring twenty by ten by two 
centimetres (eight by four inches by half an inch), and 
each piece being folded once, a piece of thread is at- 
tached to the loop, and the ends are rounded off with 
scissors. Plate XIII., Fig. 5. 

Bandages are always being required, and a good 

Fig. 19. 




Modified Scultetus bandage. 



supply made from gauze and flannel should be kept 
on hand. They should be of different widths, and, in 
order to insure straight margins, should be cut by 



112 



ASEPTIC SURGICAL TECHNIQUE. 



Fig. 20. 



" drawn thread." Besides these, the ordinary T bandage 
and the modified Scultetus bandage (Fig. 19) should 
be always kept in stock. All bandages are to be 
sterilized in the way described above for dressings of 
the same material. 

Instead of ordinary marine sponges we now employ 
substitutes made from sterilized gauze. The gauze 
employed for this purpose is the same as that used for 
dressings. Sponges may also be made by wrapping cot- 
ton somewhat loosely in squares of gauze, the corners 
being brought together and tied at the top with thread. 
(Fig. 20.) When employing gauze for sponges, the cut 

edges should be folded in 
and hemmed, or folded in 
so that no loose threads 
are left in the field of 
operation. Such sponges 
can be made of various 
sizes, and can be easily 
sterilized by means of 
steam heat immediately 
before the operation. Or 
a supply may be sterilized 
and kept in packages, or in a jar of a solution of 
bichloride of mercury (one to five hundred) till just 
before the operation, when they are to be removed from 
the solution and thoroughly rinsed in sterile water or 
in sterile salt solution. In buying marine sponges the 
cheap reef variety and those that are in the rough will 
serve every purpose. They generally arrive packed so 




Sponge made of cotton and gauze. 



SPONGES. 113 

tightly together as to form almost a solid mass. They 
should first be carefully separated, placed in a muslin 
bag, and well pounded, to remove all particles of sand 
and other foreign materials. They are then rinsed out 
in water several times. A very good way is to place 
them in a basin or pail and allow the water to run in 
upon them from a tap for several hours. They are 
next soaked in a saturated solution of permanganate 
of potassium, are afterwards decolorized in a solution 
of oxalic or of sulphuric acid, and are then left for 
twenty-four hours in an aqueous solution of hydro- 
chloric acid, made strong enough to taste slightly sour. 
After this they are again soaked in water until the 
washings are clear. They are next placed in a bichlo- 
ride solution (one to five hundred) for twelve hours, 
and finally are rinsed in warm water and preserved in 
covered glass jars containing a three-per-cent. aqueous 
solution of carbolic acid, the solution being changed 
every week. Plate XIIL, Fig. 4. When required for 
use the sponges may be taken out, after the hands have 
been thoroughly sterilized, and dropped into a ster- 
ilized pitcher which contains sterilized water. The 
excess of carbolic acid is now squeezed out, the water 
being changed two or three times. The sponges are 
then placed in basins, which should contain sufficient 
sterile salt solution to cover them completely. 

The gauze sponges are easily sterilized, and are so 
inexpensive that they need never be employed more 
than once, and consequently are far preferable to ma- 
rine sponges. The latter, however, have the advan- 

8 



114 ASEPTIC SURG1VAL TECHNIQUE. 

tage of being more elastic and pliable and are there- 
fore more desirable for abdominal cases, and indeed 
in abdominal surgery are still preferred by many 
operators. Unfortunately, we cannot sterilize them 
by steam without ruining them. Although they are 
rather expensive, they should be thrown away after 
they have been used once, since the possibility of ren- 
dering them sterile after they have been covered with 
purulent and bloody substances is, to say the least, 
problematical. Schimmelbusch, in dealing with the 
sterilization of marine sponges, does not recommend 
boiling them in water or soda solution, for under such 
a procedure the sponges contract and become hard, 
but says that if, after being thoroughly cleansed, they 
be placed in a bag and immersed for half an hour in 
a one-per-cent. solution of soda (which has been boiled, 
and afterwards removed from the 'fire and allowed to 
cool to 85° or 90° C), they will be quite sterile. The 
sponges, with care, will stand this treatment several 
times. As we have said, it is far better never to use 
them a second time ; at any rate, sponges which have 
once been employed should never be admitted to an 
operation without being sterilized in this way. 



CHAPTER VIII. 

ASEPTIC DRAINAGE — GLASS AND RUBBER DRAINAGE-TUBES — 
GAUZE DRAINS— CARE OF RUBBER MATERIALS — RUBBER DAM 
— RUBBER TUBING — RUBBER GLOVES — AND ARMLETS. 

Our ideas regarding the necessity for and the effi- 
cacy of drainage in abdominal surgery have under- 
gone during the past few years the most radical 
changes. The time was when we did not close the 
wound of an abdominal section without inserting a 
large tube which reached well down among the tis- 
sues. It was then thought that infected cases — such, 
for instance, as pelvic abscesses — could never recover 
without drainage, and that even in the cleanest cases 
it was always well to insert the tube for at least a few 
hours until the so-called serous oozing had ceased, in 
order not to tax too severely the absorptive power of 
the peritoneum. !N"ow that our attention has been 
called to the importance of taking more pains with 
the minute operative details, since we have recognized 
the necessity of checking all hemorrhage, even from 
the smaller bleeding points, of avoiding any infection 
of the field from the contents of abscesses or of the 
intestines, and of making a careful peritoneal toilette, 
above all, since we have understood the effects of any 
rough handling of the tissues, we have come to look 
upon the necessity for drainage as being the exception 

115 



116 ASEPTIC SURGICAL TECHNIQUE. 

rather than the rule. Whereas a few years ago nearly 
ninety per cent, of all cases were drained, now we 
drain only from ten to fifteen per cent., and indeed, 
from bacteriological examinations made in a large 
number of cases, it has been proved that, even under 
the most favorable conditions and with the personal 
attention of trained assistants, it is extremely difficult 
to prevent the access of pyogenic micro-organisms into 
the tube. We have pointed out that the presence of 
the white staphylococcus in the skin is a constant 
menace where the way to the wound is kept open by 
a tube, and it was found that the dressing of the drain- 
age cases led almost invariably, after two or three 
times, to bacterial contamination. Whereas we used 
to be afraid to close the abdominal wound completely 
on account of the danger of sepsis, we now close it in 
every case possible, and rather hesitate, from fear of 
infection, to drain the abdomen. The objections to 
the insertion of drainage-tubes have been formulated 
recently by Dr. Welch* as follows : 

" (1) They tend to remove bacteria which may have 
gotten into a wound from the bactericidal influence 
of the tissues and animal juices. (2) Bacteria may 
travel by continuous growth or in other ways down 
the sides of a drainage-tube, and so penetrate into a 
wound which they otherwise would not enter. We 
have repeatedly been able to demonstrate this mode 
of entrance into a wound of the white staphylococcus 

* Maryland Medical Journal, 1891. 



DRAINAGE. 117 

found so commonly in the epidermis. The danger of 
leaving any part of the drainage-tube exposed to the 
air is too evident to require mention. (3) The changing 
of dressings necessitated by the presence of drainage- 
tubes increases in proportion to its frequency the 
chances of accidental infection. (4) The drainage-tube 
keeps asunder tissues which might otherwise immedi- 
ately unite. (5) Its presence as a foreign body is an 
irritant and increases exudation. (6) The withdrawal 
of tubes left for any considerable time in wounds breaks 
up forming granulations, — a circumstance which both 
prolongs the process of repair and opens the way for 
infection. Granulation tissue is an obstacle to the 
invasion of pathogenic bacteria from the surface, as 
has been proven by experiment. (7) After the re- 
moval of the tube there is left a track prone to sup- 
purate and often slow in healing." To these Professor 
Halsted has added an eighth, — viz., " Tissues which 
have been exposed to the drainage-tube are suffering 
from an insult which more or less impairs their vitality 
and hence their ability to destroy or inhibit micro- 
organisms." 

When an abdominal wound became infected subse- 
quently to an operation, it was formerly thought that 
this result was due to micro-organisms already present, 
it might be, in a pelvic abscess, or in the secretions 
about the uterine adnexa. Undoubtedly this mode 
of wound-infection may occur, but it should be re- 
membered that in a very large proportion of the cases 
of pyosalpinx the pus is sterile, any organisms which 



118 ASEPTIC SURGICAL TECHNIQUE. 

had before been present being dead. This has been 
proved many times by examination of smear cover- 
glass preparations and the study of cultures made at 
the time of the operation. Unless bacteriological ex- 
aminations have been made of such secretions or ac- 
cumulations of pus, it is impossible to feel sure that 
an infection which has followed the operation has 
come from within. 

There are cases, however, in which drainage is still 
indispensable, and the surgeon has to decide upon the 
safest and best means of employing it. 

Where tubes are employed, those made of glass, in- 
troduced by Koberle, of Strasburg, with slight mod- 
ifications, are the best, as they can be easily rendered 
sterile by being allowed to remain for an hour in a one 
to five-hundred bichloride solution. These tubes are 
straight, varying in length from twelve to fifteen centi- 
metres (four and a half to six inches), and in diameter 
from eight to ten or twelve millimetres (three-tenths 
to half an inch). Tubes curved at the end are also 
valuable where it is necessary to drain Douglas's 
pouch over the convex surface of a tumor. 

Every tube should be perforated with from nine to 
twelve holes, one millimetre (one twenty-fifth of an 
inch) in diameter, beginning from the inner end and 
extending for one-third the length of the tube. When 
the diameter of such holes is larger, portions of the 
omentum and of the small intestines are very apt to 
work through them into the lumen of the tube, and 
thus artificial strangulated hernise may be formed. 



DRAINAGE. 119 

The tube should be placed in such a position that it 
will carry off the fluid which accumulates in the most 
dependent portion of the pelvis. This is best accom- 
plished by inserting it in the cul-de-sac of Douglas, so 
that the inner part lies just behind the uterus, gently 
resting on the floor of the pelvis, while the more exter- 
nal portion lies in the abdominal incision from four to 
eight centimetres (an inch and a half to three inches) 
above the symphysis pubis. Gauze carried through 
the posterior fornix into the peritoneal cavity will often 
give satisfactory drainage. 

Capillary drainage can be obtained through the glass 
tube by means of a piece of wick, gauze, or cotton. If 
one of these substances be thoroughly sterilized and 
carefully placed in the tube, so that drainage can take 
place from the bottom, it will insure a steady capillary 
flow of fluid from the pelvis to the outside. 

A drain made of ordinary lamp-wick thoroughly ster- 
ilized is the most efficient ; next to this, narrow strips 
of gauze, twisted into rolls only large enough to enter 
the tube easily, are to be preferred. Plate XIII. , Fig. 8. 

Other means of draining the pelvis from above are 
employed. In some cases of wide-spread injury to the 
cellular tissue of the pelvis it is impossible to check 
the bleeding and drain satisfactorily by means of the 
glass tube alone. Under these circumstances it is 
often possible to effect both objects by packing long 
strips of a five-per-cent. iodoform gauze, three centi- 
metres (one inch) in width, behind and on each side of 
the uterus, the ends being brought out at the lower 



120 ASEPTIC SURGICAL TECHNIQUE. 

angle of the wound. Firmer pressure can be made and 
drainage secured by folding or coiling the gauze, as it 
is placed in the pelvis, in the form of a spiral, one end 
being brought out through a drainage-tube. The press- 
ure on the tube, and through this on the gauze packed 
in the pelvis, can be regulated by tightening or loosen- 
ing the abdominal binder. 

A pack introduced in this way can be removed with 
very little disturbance by slightly raising the tube and 
pulling the gauze out through it layer by layer. There 
is thus no danger of drawing out intestines or omentum 
with the dressing. 

If the tube be placed in a proper position, so that 
capillary drainage be provided for in some such way as 
we have described, there will not only be a continuous 
flow from the peritoneal cavity to the outside, but the 
tube will not need cleansing as frequently as has been 
generally thought necessary. 

It is useless to remove the dressings every hour or 
two and expose the patient to the risk of a septic infec- 
tion by repeatedly cleaning out the tube. A tube which 
has been put in properly can safely be left to care for 
itself for a period of from twelve to twenty-four hours, 
after which time it will be necessary to uncover it in 
order to remove the overlying dressings which have 
become saturated by the discharges. 

In fifty cases thus drained, this point has been tested 
by allowing the tubes to remain undisturbed for from 
twenty-four to forty-eight hours, and in not one was a 
single unfavorable symptom observed. 



DRAINAGE. 121 

The importance of perfect cleanliness in dressing the 
tube is not usually sufficiently appreciated. Hands, 
instruments, and dressings employed must be as thor- 
oughly aseptic as at the time of the operation, if we 
wish to avoid the danger of introducing infection from 
without. 

For the purpose of cleaning out the tube, the tube- 
forceps devised by Dr. Kelly has proved very valuable 
in facilitating rapid and cleanly work. Plate III., Fig. 
2. The instrument is provided with two very slender 
tapering handles, crossing like scissors, the blades 
below being furnished with rat-teeth to hold the little 
ball of cotton which is to be carried down to the bot- 
tom of the tube. The blades are fastened by a new 
style of lock devised for the purpose, as shown in the 
cut. 

A piece of sterilized cotton, sponge, or gauze small 
enough to pass easily down to the bottom of the tube 
is grasped in the forceps, gently guided down into the 
pelvis, and again withdrawn, bringing up with it the 
secretions, the process being repeated with a fresh 
pledget until the tube is dry. 

This is generally the better method, but if there is 
much secretion, a small metal or glass syringe may be 
used with a small rubber catheter. These can be 
readily sterilized in boiling water. 

It is necessary at each dressing, after cleaning the 
tube, to rotate it at least two or three times. It will 
sometimes be found, as we have said above, especially 
where the perforations are of somewhat large calibre, 



122 ASEPTIC SURGICAL TECHNIQUE. 

that pieces of omentum as large as split peas have 
become firmly fixed in the holes in the tube, forming 
veritable omental hernise. Sometimes all the holes on 
one side will thus be choked. If gentle rotation and 
traction fail to effect a release of the omentum, the 
tube must be carefully lifted up far enough to permit 
of a ligature being passed on the outside of it around 
each little hernial mass in turn ; after the ligature has 
been tied the tube should be cut loose with a pair of 
delicate long-bladed scissors or with a slender knife. 
If the intestine should be caught in this way, it must 
be released by traction and careful pressure from the 
outside of the tube, made by means of a small piece 
of cotton or gauze in the grasp of the tube-forceps. 

To decide how long the tube shall be left in the 
abdomen is in some cases a difficult matter. It must 
be borne in mind that the tube is inserted for the pur- 
pose of drainage, and that, its function being over, it 
should be removed as soon as the flow of fluid is not 
more than enough to wet the plug in it. This point 
may be reached in from twelve to twenty-four hours, 
or in some instances not until the fourth or fifth day. 
The early removal of the tube relieves the patient of 
discomfort and consequent mental anxiety; it also 
allows the fresh tissues in the track of the tube to 
come together, so that immediate union is promoted 
and the liability to ventral hernia at a later date is 
diminished. 

If there is but a scanty flow of serum on the dress- 
ing about it, and the general condition of the patient 



DRAINAGE. 123 

is good, the tube may be removed without fear, and 
any slight secretion left to the care of the peritoneum. 
If, on the other hand, the pulse and temperature are 
of such a character as to occasion anxiety, the pulse 
being 120 or more and the temperature over 100° F., 
although the discharge may be but slight, it is better 
net to remove the tube and close the wound until 
the flow has entirely ceased. 

When the tube has been removed and a slight dis- 
charge still remains, we may keep the track open by 
inserting a piece of twisted gauze, which is changed 
once in twelve or twenty-four hours, a few grains of 
the iodoform and boric acid powder (one to seven) be- 
ing dusted into the wound at each dressing. This pro- 
cedure, while allowing the sinus to close up gradually, 
at the same time provides for the carrying off of any 
noxious fluids which would otherwise tend to accumu- 
late. Where there exists a free purulent discharge 
from the first, the tube should not be removed until 
one or two weeks have passed, otherwise we are liable 
to have a formation of pockets of pus in the pelvis. 

Another more gradual method of removing the tube 
may be employed when the discharge is rapidly dimin- 
ishing and does not amount to more than a few tea- 
spoonfuls in twenty-four hours. At each dressing the 
tube may be rotated and raised from one to two cen- 
timetres. Before its final removal the tube should be 
cleansed as thoroughly as possible and rotated to make 
sure that the intestines are free. The thumb is then 
placed over the end, and the tube, being grasped be- 



124 ASEPTIC SURGICAL TECHNIQUE. 

tween the first and middle fingers, is slowly and gently 
removed. As soon as it is out, the wound is dried 
and the provisional sutures are drawn up, thus closing 
the track of the tube in the abdominal wall. The pro- 
visional sutures consist of one or two passed through 
both sides of the abdominal incision round the tube, 
and left loose until they are required for this purpose. 

Drainage by means of the gauze bag also gives very 
good results. A pack made up of several strips of 
sterilized gauze is inserted into a long, narrow gauze 
bag and used as the tube ; this causes a rapid removal 
of the fluid by capillary attraction. Plate XIII. , Fig. 8. 

Two useful canons in gynecology are : (1) drain 
rarely and only when absolutely necessary, and (2) 
when employing drainage let it be thorough. 

The rubber dam is also a useful adjunct to our stock of 
dressing materials. Where a glass tube is employed 
for the purpose of drainage after an abdominal section, 
it is convenient to have a strip of sterilized rubber dam 
twenty-four centimetres (ten inches) wide (of the same 
kind as that used by dentists or a little thicker) and 
long enough to extend from the symphysis pubis to the 
umbilicus. A slit is made down the middle of this, 
through which the top of the drainage-tube projects. 
After the gauze has been packed into the drainage-tube 
and the cotton placed immediately over it, the ends of 
the rubber dam are folded in over the cotton. Over 
this comes an additional layer of absorbent cotton, and 
a bandage is applied to cover the whole. The rubber 
dam thus holds the dressing immediately over the tube 



RUBBER GLOVES. 125 

in place and tends to prevent the penetration of any 
fluids beyond this limit. Since the rubber comes in 
such close contact with the wound and the abdominal 
cavity, it is, of course, very necessary that it should be 
thoroughly sterilized. To effect this it may be boiled 
for five minutes in a one-per-cent. soda solution and 
afterwards preserved in a glass jar containing a one 
to twenty aqueous solution of carbolic acid. When 
required for use it is removed from the jar with the 
necessary precautions, and then rinsed off in sterile 
warm water before being placed in position. 

Rubber tubing, besides being used sometimes for drain- 
age, is convenient for constricting the uterus while a 
myoma is being removed from it. It comes in several 
sizes and costs about twenty-five cents per metre. It 
can be sterilized in soda solution and kept till it is 
needed, in the same way as the rubber dam, in a stop- 
pered glass bottle containing a five-per-cent. aqueous 
solution of carbolic acid. In order to make quite sure 
that it is perfectly sterile, it will perhaps be best to 
boil the piece about to be used in a one-per-cent. soda 
solution just before the operation. Rubber dam and 
rubber tubing should not be kept in solutions of sub- 
limate, owing to the chemical action exerted upon 
them by this substance. 

Rubber gloves and armlets* should be more exten- 
sively used. It is probable that the chances of infection 

* These gloves may be bought of the Goodyear Rubber Co., New 
York. 



126 ASEPTIC SURGICAL TECHNIQUE. 

would be very much diminished if the assistants were 
required to wear them at operations, since they can be 
rendered absolutely sterile, which is not necessarily 
true of the skin of the hands. Their use by the oper- 
ator himself would also facilitate the performance of a 
great deal of minor work without any inconvenience 
resulting therefrom . If the gloves are worn after being 
sterilized by being boiled in a one-per-cent. soda solu- 
tion, it will be necessary to scrub the hands and fore- 
arms only once or twice, and, as we have pointed out 
above, their use will often prevent contamination. 
(Chapter III.) Since the first edition of this book 
appeared I have become convinced that for any dis- 
advantages connected with them the operator is more 
than compensated by the lessening of risk to his patient. 
They will stand sterilization in soda solution many 
times without injury. They come in different sizes, 
and it is best to wear a pair which fit the hands very 
loosely, in order to facilitate putting them on and off. 
Those with the long wristlets are the most serviceable, 
as they protect a considerable portion of the forearms. 
When putting the gloves on or taking them off, care 
should be exercised, on account of their delicate struc- 
ture, not to handle them roughly. If one experiences 
any difficulty in getting them on, they can be filled 
with the solution contained in the vessel until the 
fingers of the glove become distended, after which they 
can be slipped on quite easily. The hand is then held 
up and the solution is allowed to run out. If they stick 
at all when one attempts to remove them, they should 



RUBBER GLOVES. 127 

be gently turned inside out. After the operations are 
over for the day, the gloves may be washed off thor- 
oughly, hung up to dry, and afterwards put away, to 
be sterilized in soda solution immediately before the 
next operation. 



CHAPTER IX. 

FLUIDS FOR IRRIGATION — PLAIN STERILE WATER — ANTISEPTIC 
FLUIDS FOR IRRIGATION — STERILE PHYSIOLOGICAL SALT 
SOLUTION — ANTISEPTIC POWDERS— IODOFORMIZED OIL — BI- 
CHLORIDE CELLOIDIN — IODOFORMIZED CELLOIDIN — SILVER 
FOIL — GUTTA-PERCHA. 

It is the custom of many surgeons to irrigate the 
abdominal cavity after almost every operation, while 
others use this method only in those cases where fluid 
has escaped into it during the removal of a tumor, or 
where the bleeding from the separated adhesions has 
been marked. The substances which have been used 
for this purpose are plain hot water, sterile salt solu- 
tion, and a variety of so-called antiseptic solutions. 
The routine treatment of irrigating every case cannot 
now be considered a necessary practice. Where the 
structures are non-adherent and there have been no 
complications, there would seem to be no indication 
for its employment, but after the removal of a mass 
which contains bloody or purulent fluid, or where a 
great deal of oozing has occurred as a consequence 
of the separation of dense adhesions, irrigation may 
sometimes be useful. If the fluid that has escaped be 
of a septic nature, the advantage of irrigating the 
pelvic cavity under these circumstances has been dis- 
puted, and it is not unreasonable to suppose that when 
such material has escaped into the abdominal cavity, 
128 



IRRIGATION. 129 

attempts to remove it by irrigation might be apt to 
spread it farther about between the coils of the in- 
testines and into parts of the abdominal cavity whence 
it would be impossible to remove it by any subsequent 
sponging. If solutions containing germicidal drugs 
are used for irrigating the abdominal cavity, there is 
not only the uncertainty that the drug may not prove 
of sufficient strength to destroy the septic material 
which remains, but there is also the danger of causing 
local lesions, as well as of subsequent results from the 
absorption of toxic chemical substances. Fortunately, 
in the majority of cases the fluid which is contained 
in old abscess cavities in the pelvis does not contain 
living organisms. This fact has been proved by cul- 
tural experiments, and explains why in these cases in- 
fection has not occurred, though pus has escaped at 
the time of the operation. When it happens that, 
through accident during the removal of an ovary for 
malignant disease, it ruptures and the contents of the 
tumor escape into the pelvic cavity, it is above all 
things necessary to remove the escaped particles of 
tumor material, so that the formation of metastases 
upon the peritoneal surface may be prevented. 

In the past few years we have obtained excellent 
results in pus cases by free irrigation, in this way re- 
moving all the morbid material possible, the remainder 
being diluted by the fluid with which the abdominal 
cavity is filled after the irrigation has been completed. 

In selecting a fluid for abdominal irrigation we 

naturally look for one that promises the best possible 

9 



130 ASEPTIC SURGICAL TECHNIQUE. 

results with the minimum possible amount of harm, 
and up to the present time none has proved more satis- 
factory than the warm sterile normal salt solution. Of 
its advantages and of the way of preparing it I shall 
speak in a few moments. 

The fluid which has perhaps been most generally 
used is plain water. It can easily be rendered sterile 
by boiling it in a clean vessel just before the operation. 
It is well to have two vessels, one of sterilized water 
which has been allowed to cool, and the other contain- 
ing water still hot. When required for irrigation, the 
water from the two vessels is mixed until the proper 
temperature is obtained (from 43° to 48° C. (110° to 
118° F.)). The water should be in a perfectly clean 
pitcher or graduate, and from this it is poured into the 
abdominal cavity. 

With plain sterile warm water we not only aim at 
cleansing the abdominal cavity but also at stimulating 
the circulation, and thus in a measure overcoming the 
tendency to shock. The principal objection to the use 
of plain water for irrigation is that it has a definite 
deleterious effect upon the tissues. It is a fact well 
known to microscopists that when fresh animal tissues 
are examined in plain water the cells are seriously 
altered and, as has been shown by repeated experi- 
ments, the red and white blood-corpuscles are injured 
or completely broken up by its action. 

The use of solutions of sublimate and carbolic acid 
for irrigation of the peritoneal cavity must now be 
unhesitatingly condemned, both on account of the 



NORMAL SALT SOLUTION. 131 

local necrotic effects which are produced and because 
of the danger of general intoxication. The experi- 
ments which have been made with dilute solutions of 
sublimate upon the abdominal cavity of dogs are too 
well known to need any description here; and yet 
not a few abdominal surgeons long persisted in pour- 
ing this poison into the abdominal cavity, notwith- 
standing the fact that autopsies had proved that the 
patients sometimes died afterwards with intestinal 
ulceration and peritonitis, or with lesions of the heart 
and kidneys, of which there was no evidence before 
the operation. (See page 39.) 

Of the milder antiseptic solutions, such as one-half- to 
two-per-cent. solutions of boric acid, Thiersch's solution 
of salicylic acid, and the like, it may be said that they 
possess no advantages over the simple solution of com- 
mon salt. This is made to correspond in specific grav- 
ity very closely with the normal serum of the blood, 
whence the term " normal" or " physiological" salt so- 
lution. It is prepared by dissolving six grammes (3iss) 
of sodium chloride in each litre (33J ounces) of distilled 
water. This solution is filtered into a clean flask which 
may hold about three litres. Plate XIV., Fig. 1. The 
flask is plugged with non-absorbent cotton, the top of 
the plug being securely wrapped in a gauze bandage 
in order to prevent the deposition of dust on the rim 
of the flask. After being heated over a Bunsen flame 
until the fluid boils, it is immediately transferred to an 
Arnold steam sterilizer, already heated to 100° C, and 
allowed to remain there for half an hour. The process 



132 



ASEPTIC SURGICAL TECHNIQUE, 



is repeated on the two following days. The fluid is 
to be used at a temperature of 43° C. (110° F.) or as 
high as 48° C. (118° F.). It can be made up in 
quantities of one dozen flasks or more, and kept all 
ready for use. When required for use, two flasks are 
taken, one containing cold and the other hot solution, 
and their contents mixed in a sterile glass graduate 
to which a thermometer is attached, and which holds 
from five hundred to one thousand cubic centimetres. 
(Fig. 21.) This jar must, of course, have been ren- 

Fig. 21. 




Thermometer jar. (Robb.) 

dered perfectly sterile in the same way as the glass 
trays for the instruments. The gauze and plug 
having been removed with due precautions, the cold 
salt solution is first poured into the thermometer jar 
and then enough of the hot solution is added to 



PLATE XIV. 




Fig. 1.— Sterile salt solution in flasks. 




Fig. 2,— Glass jar containing irrigating fluid, with tube and nozzle attached. 



NORMAL SALT SOLUTION. 133 

raise it to the proper temperature. The thermom- 
eter affords the best means of testing the temper- 
ature of the water, and the hand of the assistant or 
nurse should not be relied upon. Such loose de- 
terminations are inaccurate, and, what is more im- 
portant still, the hands may contaminate the fluid. 
This is a detail of importance, and the careful observ- 
ance of it should be insisted upon. 

The solution is poured into the abdominal cavity 
directly from the glass graduate, or it can be siphoned 
through a glass or hard-rubber nozzle attached to a 
piece of rubber tubing ; or if preferred a new Davidson 
syringe, previously sterilized in boiling soda solution, 
with a glass nozzle attached, may be employed. The 
Davidson syringe suitable for this purpose can be 
bought without the usual attachments for the irri- 
gating end, and so be less expensive. The glass nozzle 
can be readily attached to the end of the tube, and 
its lumen, being so much larger than that of the 
ordinary nozzles which come with these syringes, will 
permit a much larger flow through it, and besides can 
also be much more easily sterilized. (Fig. 22.) 

In performing plastic operations, irrigation is not 
only very necessary, but its use dispenses with the 
necessity of sponging. A constant stream can be em- 
ployed and be so regulated as to keep the field of 
operation free from the blood that would otherwise 
obscure it and hamper the operator. The fluids used 
for this purpose are either warm sterile water or, 
better still, sterilized normal salt solution. The solu- 



134 



ASEPTIC SURGICAL TECHNIQUE. 






5.V!" "...-..■: 

ilii 



tion is placed in a sterile glass jar (Plate XTV\, Fig. 2) 
Fig 22 fitted with a piece of rubber tubing 

which is provided with a glass or hard 
rubber syringe stopcock by which the 
current is controlled. The handy little 
apparatus devised by Edebohls, of New 
York, can be readily sterilized and will 
prove eminently satisfactory. Instead 
of a glass jar, a rubber bag large 
enough to contain two litres may be 
used. Such rubber bags are sold under 
the name of fountain syringes, and are 
to be rendered sterile in the manner 
described for other rubber materials. 

The poioders most frequently em- 
ployed in surgery consist of iodoform 
and boric acid, either alone or in com- 
bination. The iodoform, when used 
alone, should be well rubbed up, as it 
is very apt to become lumpy, and it 
should be lightly dusted over the sur- 
face of the wound. Iodoform, perhaps, 
is the best germicidal powder that we 
have. Boric acid is frequently em- 
ployed in the same manner as iodo- 
form. The chief objection to using 
powders at all is that, while the sub- 
stances may, perhaps, preserve their 
Glass Xbb e ) n0ZZle germicidal power when in solution, it 
is difficult to have them perfectly sterile when in the 



ANTISEPTIC POWDERS. 135 

form of dry powder. Iodoform and boric acid (one part 
of the former to seven parts of the latter) placed in igni- 
tion tubes and sterilized in the autoclave afford a valu- 
able mixture, and one often employed, since the powder 
possesses the advantage of being non-irritating. After 
an operation it is well to dust this powder just along the 
line of the incision or on the gauze which protects it. 
After an abdominal section, when we wish to close the 
wound immediately, we protect it first with the occlu- 
sive dressing shortly to be described, and then incor- 
porate the iodoform and boric powder in the celloidin 
after it has been poured over the gauze. In plastic 
cases we dust the powder well over the field of opera- 
tion, and also use a small quantity of it each time after 
catheterizing the patient, the powder being dusted 
over the field of operation and the external geni- 
talia. 

Some patients are extremely susceptible to the toxic 
effects of iodoform, even when very small quantities 
are employed. Under these circumstances we can 
use either the boric powder alone or a powder com- 
posed of one part of subiodide of bismuth to seven 
parts of boric acid. The powders should be kept in 
sterilized glass vessels, and when they are to be ap- 
plied to a wound should be shaken from a special flask 
that has first been sterilized. Such a powder-box can 
be cheaply and easily made by covering the mouth of 
a bottle made of glass or metal with a piece of wire 
screen. The meshes should not be too coarse, or the 
powder will escape too freely. (Fig. 23.) 



136 ASEPTIC SURGICAL TECHNIQUE. 

On account of the danger of poisoning by iodoform, 
salol has been recommended as a substitute for it. 

Pig. 23. 




Aseptic powder-flask. (Robb.) 

Iodoformized oil, which is a combination of oil and 
iodoform powder, often employed locally, can be mixed 
according to the following recipe. The oil (olive oil 
or oil of sweet almonds) is sterilized in a flask, plugged 
with cotton, for an hour on three successive days, and 
iodoform powder in the proportion of one part to four 
parts of oil is added just before the preparation is to be 



IODOFORMIZED OIL. 137 

used. In making this combination it will be necessary 
to use a sterilized glass rod and dish, and in order to 
insure asepsis, Bohm has suggested that the iodoform 
powder should be first carefully washed in an aqueous 
solution of sublimate and afterwards dried. 

Occlusive dressings are frequently used to protect 
wounds. The solution which is perhaps most often 
used for this purpose in abdominal cases is that known 
as bichloride celloidin. The advantages of such a dress- 
ing, as has already been stated, lie in the fact that it not 
only protects the wound from infection from without, 
but will remain in place for a considerable length of 
time, and in a measure acts as a splint, allowing of a 

certain amount of movement on the part of the patient 

i 

without any disturbance of the wound. 

Bichloride celloidin (one to sixteen thousand) may be 
made according to the following formula : 

R Ether (Squibb 's), 

Absolute alcohol, aa 200 cubic centimetres (6| ounces) ; 
Of a solution made of one gramme (15 grains) of bichloride crystals 
dissolved in 40 cubic centimetres (10 drachms) of absolute alco- 
hol, 1 cubic centimetre (16 minims). 
Mix and add of Anthony's " Snowy Cotton" enough to give the 
solution the consistence of simple syrup. 

To the skin of some patients the bichloride in this 
strength will act as an irritant, and in such cases it is 
better to use a similar preparation of the strength of 
one to thirty-two thousand. 

The occlusive dressing is simple and gives satis- 
factory results. The method of procedure is some- 



138 ASEPTIC SURGICAL TECHNIQUE. 

what as follows. After the wound has been closed and 
the skin in the line of the incision and the sutures have 
been dried, they are covered with a piece of sterile 
cheese-cloth. This is fixed in its place by being satu- 
rated with the celloidin mixture, which can be evenly 
distributed over the surface of the gauze with a steril- 
ized glass spatula. Over it is dusted some of the mix- 
ture of iodoform and boric acid powder (one to seven). 
A second piece of gauze considerably larger than the 
first is next applied, over which more celloidin is poured 
and more of the powder of iodoform and boric acid is 
dusted on. The dressing soon becomes dry and fixed. 
Over all is placed a mass of sterilized absorbent cotton, 
which is held in place by a binder. A wound which 
has been covered with this dressing may be left for 
a week or more if everything goes well. When the 
dressing is to be removed, it should be well softened 
either with warm sterile water or with a one to forty 
aqueous solution of carbolic acid applied on lint or 
cotton. This should be allowed to remain over the 
dressing for an hour or so before any attempt at re- 
moval is made, but, if necessary, the dressing may be 
loosened in a few minutes by pouring ether over it. 

lodoformized celloidin may be used in the same manner 
as the bichloride celloidin. It is made as follows : 

R Absolute alcohol, 200 cubic centimetres (6 \ ounces) ; 
Iodoform powder, 50 grammes (12£ drachms) ; 
Mix and add ether, 200 cubic centimetres (6 J ounces). 
Mix and add of Anthony's " Snowy Cotton" enough to give the 
solution the consistence of simple syrup. 



OCCLUSIVE DRESSINGS. 139 

When making any of these celloidin mixtures, abso- 
lutely dry graduates and bottles must be used. These 
may be obtained by first rinsing them out with absolute 
alcohol, then with pure ether, the latter being then 
allowed to evaporate. In the preparation there must 
be as little exposure to the air as possible. The " snowy 
cotton" is to be added in small pieces and the bottle well 
shaken after each addition. Wide-mouthed flasks are 
the most convenient for the purpose. 

Silver foil is used by some surgeons as an occlusive 
dressing. It is procured in tissue-paper booklets, each 
containing two dozen sheets. For sterilization, after 
the bound edge is cut off, the booklet is placed between 
two boards (quarter-inch poplar or white-wood boards 
are used, as these do not warp), wrapped up in muslin, 
and sterilized with the other dressings. The sheets 
are picked up on gauze wet with alcohol, and placed 
over the incision, which has been thoroughly dried. 
Over this the ordinary dressings are placed. 

Gutta-percha tissue is sometimes used. 



CHAPTER X. 

ON CERTAIN PROCEDURES SOMETIMES NECESSARY BEFORE AND 
AFTER OPERATIONS, WHICH MUST BE CONDUCTED ASEPTI- 
CALLY — HYPODERMIC INJECTIONS — EXPLORATORY PUNC- 
TURES — CATHETERIZATION — BLADDER- WASHING — URETERAL 
CATHETERIZATION. 

Of the ordinary precautions to be taken in choosing 
a site for a hypodermic injection and of the anatomical 
structures to be avoided, it is not necessary to speak 
here. These points have been fully treated of in other 
works, and, as a rule, the suggestions made therein 
are carefully noted and acted upon. Unfortunately, 
hitherto sufficient attention has not been paid to the 
need of aseptic methods in making the ordinary hypo^ 
dermic puncture, and it is a very common occurrence 
for even a good physician to take a hypodermic syringe 
from its case, dissolve a tablet in water, immediately 
fill the syringe, and at once plunge the needle into the 
subcutaneous tissues. It is more than probable that 
the risk of puncturing a vein, of injecting the perios- 
teum, and the like, is no greater than is the danger of 
setting up an infectious process, so that one of the most 
important points to be attended to is that the puncture 
be made aseptically. That the danger of sepsis is by 
no means merely hypothetical is evidenced by the large 
number of cases of hypodermic puncture which have 

140 



HYPODERMIC INJECTIONS. 141 

been followed by abscess formation or localized phleg- 
mons, and we have only to refer to the careful mono- 
graph of Fraenkel, of Hamburg, on gas phlegmons, in 
which he reports two cases of fatal spreading gangrene 
following hypodermic puncture, to illustrate further 
the danger which lurks beneath this ordinarily simple 
operation. The importance of sterilizing the hypo- 
dermic syringe after using it upon one patient before 
employing it again is shown by the cases on record 
in which erysipelas, anthrax, and tuberculosis have 
actually been transmitted through the medium of the 
hypodermic syringe. The sources of infection to be 
particularly remembered in giving hypodermic injec- 
tions are the following : (1) the syringe and its needles, 
(2) the fluids to be injected, (3) the skin of the patient, 
(4) the hands of the operator. Although the dangers 
of an infection from the two last-named sources are not 
very great, yet the careful surgeon will disinfect both 
his own hands and the skin of his patient before intro- 
ducing the hypodermic needle. Fortunately, solutions 
of drugs, such as quinine, antipyrin, and apomorphine, 
sometimes used for hypodermic injections, possess a cer- 
tain amount of antiseptic power which tends to prevent 
the development and multiplication of pyogenic bac- 
teria in them. On the other hand, solutions of the 
drugs in most common use, such as atropine, morphine, 
cocaine, and ergotine, favor the development of bac- 
teria, and when kept too long, or if made without 
proper precautions, are frequently found to be swarm- 
ing with micro-organisms, with the result that not only 



142 ASEPTIC SURGICAL TECHNIQUE. 

are their medical properties sometimes impaired, but 
thousands of micro-organisms may be placed in the 
subcutaneous tissues; and even though the greater 
number of them may be harmless, at other times there 
may be pyogenic bacteria present which will give rise 
to the formation of local abscesses which are likely 
to prove very troublesome and even dangerous to 
life. 

Fluids used for hypodermic injections should be 
sterile. When hypodermic injections of a drug are 
given only rarely, it is best to make up a fresh solution 
each time. In private practice, where the tablets are 
so much used, a very simple expedient enables us to 
make a practically sterile solution at a few minutes' 
notice. A dessertspoonful of water is held over a lamp 
until the water boils. A tablet is then allowed to roll 
from its phial into the spoon. This immediately dis- 
solves and we have a practically sterile solution. Of 
course, where the drug is one which is injured by a 
temperature of 100° C. (212° F.), the best we can do is 
to have the water boiled and allowed to cool somewhat 
before the tablet is placed in it. 

Even in hospitals, where stock hypodermic solutions 
must be kept in the operating-room, it is best not to 
make too large a quantity at once. In the case of the 
majority of solutions which have been prepared asep- 
tically, the addition of from two to three drops of pure 
carbolic acid to thirty cubic centimetres (1 ounce) of 
the solution will prevent the development of bacteria 
and at the same time will not be sufficient to do any 



PARACENTESIS. 143 

injury. Cocaine may be dissolved in various men- 
strua, but keeps best in a one to ten-thousand solution 
of corrosive sublimate. 

The sterilization of hypodermic syringes has been 
and is still a difficult problem : the complexity of the 
instrument, and especially the inaccessibility of the 
piston, render it by no means easy to free from germs. 
The ingenious syringe of Koch has no piston and is 
easily sterilized, but it is too inconvenient for practi- 
cal use, and the many improvements suggested have 
as yet failed to give us a satisfactory instrument. The 
syringes made entirely of glass with asbestos pistons, 
if they are well made, are very satisfactory for a time, 
but the asbestos piston soon gets out of order. The 
piston should be withdrawn from the barrel and both 
placed in a five-per-cent. solution of carbolic acid, 
which will render them sterile. Just before the 
syringe is used sterile water is drawn through it. 
Metal syringes as well as the needles can be boiled in 
a one-per-cent. soda solution. Hypodermic needles 
made of platinum can be rendered perfectly sterile 
by heating them in the flame of a Bunsen burner or 
of an alcohol lamp, but exposure of the ordinary 
needles to the flame soon ruins them. 

Exploratory puncture and paracentesis are not so fre- 
quently resorted to as in former days, chiefly because 
radical operations with our present methods are now 
not accompanied by much greater risks. It is still oc- 
casionally necessary, however, to draw off the fluid from 
the chest or the abdomen in cases of pleurisy, ascites, 



144 ASEPTIC SURGICAL TECHNIQUE. 

or in other conditions, either for purposes of diagnosis 
or for the relief of the patient. The needle, trocar, 
or rubber tubes used should be sterilized in a one-per- 
cent, soda solution, and the skin of the patient as well 
as the hands of the operator prepared according to the 
principles already laid down. 

Catheterization of the female bladder is so simple a 
procedure that it seems almost superfluous to do more 
than mention it in a book on surgical technique. 
But, although so simple, there is probably no operation 
which is so often done improperly, and the nurse or 
physician has been responsible over and over again, 
through oversight or carelessness, for the setting up 
of a serious infection of the bladder, or even of fatal 
suppuration in the kidneys or their pelves. The nor- 
mal urine is probably always sterile, bacteria being 
discharged through the kidney only when there are 
lesions in the renal parenchyma. In the majority of 
the cases of infection of the urinary passages the patho- 
genic bacteria have gained entrance from below. It 
is interesting to note, too, that one of the most fre- 
quent micro-organisms associated with cystitis, pyelitis, 
and pyelonephritis is a bacterium indistinguishable by 
laboratory methods from the bacillus coli communis. 
The staphylococcus, streptococcus, and proteus vulgaris 
are also sometimes present in cases of cystitis. These 
facts should teach us the importance of thoroughly 
cleansing the external parts before we undertake the 
catheterization of the bladder. The physician should 
not only always take care himself, but also instruct 



CA TEETER1ZA TION. 145 

the nurse to make sure that no possible precaution for 
the prevention of infection is neglected. 

For catheterization the patient lies in the dorsal 
position with the knees somewhat separated. A sheet 
or blanket is thrown over the thighs and reaches down 
to the knees, leaving the vulva exposed. " Catheteri- 
zation in the dark" is no longer justifiable. The labia 
are held apart with a gauze sponge, and the meatus 
urinarius and the parts around it are thoroughly 
cleansed with a cotton sponge and warm boric solu- 
tion before the catheter is inserted. One great diffi- 
culty in the way of an aseptic catheterization of the 
male has lain in the impossibility of sterilizing the 
gum-elastic catheters, which are still often used, with- 
out at the same time injuring them. Fortunately, in 
the female this difficulty has been obviated by the in- 
troduction of the simple glass catheter (Fig. 24), which 



Fig. 24 




Glass catheter. 

is easily rendered sterile by being well scrubbed with 
soap and water and afterwards being placed in a Hve- 
per-cent. solution of carbolic acid for five minutes. A 
number of them may be cleansed at the same time, if 
desired, and kept in a one to twenty solution of car- 
bolic acid. (Fig. 25.) Whenever one is needed, it is 
removed from the jar and placed in a basin containing 

10 



146 



ASEPTIC SURGICAL TECHNIQUE. 




Glass catheters in one to 
twenty carbolic acid solution. 



a warm boric acid solution. If by chance a glass 
catheter is not available, rubber or silver catheters 

may be employed after having 
IG * ' been boiled in the one-per-cent. 

soda solution. For a lubricant, 
sterilized oil or glycerin may be 
used. If the glass catheter be 
used no lubricant is necessary. 
It has been suggested that the 
urethra should be washed out 
carefully with some sterile fluid 
before catheterization, inasmuch 
as this takes away a certain num- 
ber of bacteria. In the female it 
has been shown that the chances 
of contamination from the urethra, in the absence of 
a definite urethritis, are very slight. 

After a catheter has once been used it should be 
thoroughly cleansed before it is put away ; and here 
mechanical means are of great importance. The out- 
side should be scrubbed with brush and soap, and hot 
water or soda solution should be syringed through it 
until the lumen is thoroughly clean. The catheter is 
then placed in a jar containing a one to twenty solu- 
tion of carbolic acid until again required for use. 

Irrigation of the bladder is often indicated, and for 
this purpose a sterilized solution of boric acid or nor- 
mal salt solution is generally used. The warm solu- 
tion is filtered into a sterilized rubber bag or fountain 
syringe, the end of the conduit tube from the bag 



CA THETERIZA TION. \ 47 

being attached to the end of the sterilized catheter, 
and, after the urine has been drawn off, is allowed to 
run slowly into the bladder, the stream being con- 
trolled by a pinch- cock placed on the tube. The tube 
is disconnected from the end of the catheter after 
about two hundred cubic centimetres have run in, or 
sooner if the patient complains of pain, and the bladder 
allowed to empty itself. The process may be repeated 
two or three times, until the washings are clear. If 
desired, a two-way catheter may be employed, espe- 
cially if the distention of the bladder is at all painful. 

A very simple and convenient apparatus consists of 
a glass funnel with rubber tubing connecting to a glass 
catheter. The articles can be sterilized by boiling in 
a one-per-cent. soda solution. After the urine has been 
drawn off, the air is expelled from the tube by allowing 
a small amount of the solution to pass through it ; the 
catheter is then introduced into the bladder for a dis- 
tance of four centimetres, the solution is slowly poured 
into the funnel, and passes into the bladder, which is 
slowly distended. The funnel is then inverted below 
the edge of the table and the fluid is siphoned out. 
This procedure is repeated several times. 

Catheterization of the ureters will be described in de- 
tail elsewhere. It is necessary here simply to mention 
that the instruments, the hands of the operator, and 
the external genitalia are disinfected thoroughly ac- 
cording to the methods already described. 



CHAPTER XL 

THE GYNECOLOGICAL OPERATING-ROOM — OPERATING-TABLE — 
INSTRUMENT-CASES AND OTHER FURNISHINGS. 

Only in a hospital can we expect to have an ideal 
operating-room ; at times we must content ourselves 
with a room fitted up at the patient's house, hut this is 
at the hest but a poor substitute. 

The operating-room in a hospital should, while being 
within a convenient distance of the wards, be so located 
that the patients in them will not be disturbed by any 
of the unavoidable noises belonging to it, nor be an- 
noyed by the smell of the fumes of the anaesthetic. 
There should be good-sized windows at the sides and 
in the roof, so arranged that most of the light comes 
from the north. It will be of advantage to have several 
smaller rooms adjoining the operating-room, — a dress- 
ing-room for the operator and his assistants, a store- 
room for supplies, a room in which the anaesthetic is 
administered, and another in which the patients may 
remain, if necessary, until they have had time to re- 
cover somewhat from its effects. A water-closet with 
bath-room attached should be near at hand, and a 
photographic dark room with water-supply is a great 
convenience, as it is often desirable to make photo- 
graphs of unusual conditions upon the spot while the 
operation is in progress. These smaller rooms may be 
arranged on either side of the corridor at the end of 
148 



OPERA TING-ROOM 149 

which the operating-room is situated, the room where 
the patient is anaesthetized being provided with a 
second door which communicates directly with the 
operating-room. The corridor can, if it be absolutely 
necessary, be also used as a waiting-room. If only two 
rooms are available, the one most favorably located as 
regards the distribution of the light and the water- 
supply should be employed as the operating-room, 
while the second room is used for a supply-room, in 
which the anaesthetic can also be given. 

The operating-room of a general hospital should 
be sufficiently large to satisfy all requirements, es- 
pecially those which will facilitate the efforts for the 
maintenance of an aseptic technique. One measuring 
twenty-six feet nine inches by twenty-five feet eight 
inches, or eighteen feet by twenty-six feet six inches, 
will answer every purpose where the number of opera- 
tions does not exceed three or four daily. Everything 
about the room should be as simple and plain as possible 
and of such material and shape as will admit of a thor- 
ough mechanical cleansing and bear repeated washings 
with hot soda solution. The floor should be tiled or 
made of hard wood which has been paraffined, or white 
marble Mosaic in three-quarter-inch cubes, embedded 
in cement and polished, answers every purpose. The 
walls and ceiling are best plastered with King's cement, 
which should be coated with white enamel paint. The 
corners of the room should be rounded, in order to do 
away with crevices and nooks from which dust will 
be hard to remove. The walk and floor can thus be 
scrubbed whenever necessary without injury. (Plate 



150 



ASEPTIC SURGICAL TECHNIQUE. 



XV.) The supply of light must be abundant. Electric 
lights should be provided for night work, and a mova- 
ble lamp is needed for throwing light into the depths 
of a wound. One-half of the bulb of such a lamp 
should be silvered like a mirror on the inner surface, 
to act as a reflector. The same hemisphere is opaque 
on the outside, so as to shield the operator's eyes from 
the light. (Fig. 26.) 

A gas supply and fittings for Bunsen burners are 
necessary. The room should be heated from the gen- 
eral heating apparatus of the hospital, but if possible 

Fig. 26. 




Movable incandescent lamp. 



J I 



!^>^^^ 



an open fireplace should be added. A thermometer 
should be suspended in the room, and the temperature 
should be carefully regulated at about 80° F. 

When the patient is placed upon the cold operating- 
table during the spring, autumn, and winter months, 
when the temperature of the room is between 60° and 
70° F., there is always a certain amount of risk, in 
spite of the use of coverings and hot-water bags. The 
operator is liable to fail to appreciate to what extent 
the exposure may be affecting the patient, as he is on 
the move most of the time, and is thus to a certain 
extent able to keep up his bodily heat. Then, too, 
the patient is still further exposed during the neces- 



OPERATING TABLES. 



151 



sary cleansing of the field of operation. Finally, we 
shall take into consideration the loss of heat pro- 
duced by the inhalation of ether. This chilling of 
the patient contributes in no small measure to the 
untoward results that sometimes follow an operation, 



Fig. 27. 








Boldt's operating-table, with (author's) electric light attachment. 

viz., the development of a bronchitis, a pneumonia, 
a pleurisy, a nephritis, or a peritonitis, with or with- 
out an exaggerated condition of shock. Many minor 
post-operative discomforts, such as a stiffness of the back 
and neck, and the frequent muscular pains throughout 
the body, undoubtedly arise from the same exposure. 



152 ASEPTIC SURGICAL TECHNIQUE. 

Numerous devices have been employed for keeping 
the patient warm during an operation. Among these 
appliances are rubber bags or flat rubber pads, which 
are placed under or between the thighs or along the 
trunk. Dr. Kelly used long narrow rubber bags, filled 
with hot water, for this purpose. The objection to the 
employment of such devices lies in the fact that they 
are difficult to look after properly — the patient may 
be burned ; they shift their position, become cold, and 
prevent the patient from remaining in a fixed position 
on the table. 

For some time past, at Lakeside Hospital, we have 
used electric lamps under the table, and the results 
have been very satisfactory. The lamps are held in 
an upright position by attachments to two hollow 
movable metal tubes, which extend from the upper 
end a distance of three feet nine inches towards the 
foot of the operating-table. Nine lamps of thirty-two 
candle-power are attached to each tube. At the upper 
end of each switch is a tube so arranged that three 
lamps can be turned on at a time, thus making it pos- 
sible to control the amount of heat. The cords contain- 
ing the electric wires are brought through the floor in 
the middle of the room, and are of sufficient length to 
allow the operating-table to be moved backward or for- 
ward in the room. The supports holding the lamps can 
be removed from the table, and the attachment can be 
so arranged that it can be used wherever there are 
electric light fixtures. The patient can be cleaned up, 
or the abdominal cavity irrigated, without injury to 
the lamps. The temperature under the table may thus 



OPERATING TABLES. 153 

be raised 45° F.,and on the upper surface of the table, 
protected with a thick towel, 17.1° F. in twenty min- 
utes, thus rendering the air warm in the immediate 
vicinity of the patient. The pads usually applied are 
used on the table, and care must be used that the pa- 
tient's skin does not touch the glass top of the table, 
otherwise burns may result. The lights are lit some 
twenty minutes before the operation starts. They are 
usually turned off during the operation, but may be 
left on if the room is cold or the shock of the operation 
marked. They are turned on about the time the clo- 
sure of the incision is commenced, in order that the pa- 
tient may be warmed up before returning to the ward. 

In a series of cases observed both with the lamps 
burning, and without their use, rectal temperatures 
were noted at the end of the operations. The total 
fall of temperature in the groups of cases with whom 
the lights were used was less than half the total fall 
registered by the group with whom the lights were 
not employed. 

The operating-table may have a glass top with metal 
legs ; and both the top and the legs should be perfectly 
plain, in order that they can be thoroughly cleaned. A 
table forty-four inches (112 centimetres) long, twenty- 
one inches (54 centimetres) wide, and thirty-one inches 
(80 centimetres) high is a convenient size. It is 
well to have the legs at one end provided with rubber 
casters, so that while standing firm with the two ends 
level at other times, the table can be easily wheeled in 
any direction desired. 

Many excellent operating-tables are now upon the 



154 ASEPTIC SURGICAL TECHNIQUE. 

market, with white enameled iron frame-work and 
glass tops. A good one should have hinged sections 
at the head and at the foot that can be raised and 
lowered at will. The whole table should be so hinged 

Fig. 28. 




Dr. Halsted's semicircular table for instruments. 

that it may be tilted to place the patient in the Tren- 
delenburg position. 

We now use a Boldt table (Fig. 27), which we find 
satisfactory for gynaecological plastic work, as well as for 
abdominal sections. These can be obtained from 
Kny and Co., New York. 



Q 



i 

o 
o 





O 




tr 1 



PLATE XVI. 




Instrument case. 



PLATE XVII 




Fig. 1. — Haemostatic forceps strung on 
steel ring. 




Fig. 2. — Floating glass label. (Robb.) 



Fig. 3. — Glass basins. 





Fig. 4. — Cotton pledgets in glass bottles. 



Fig. 5. — Agate-ware vessel with top 
protected with gauze. 



ADDITIONAL FURNITURE. 155 

Tables for holding the basins or glass vessels may be 
made of the same kind of wood as the operating-table, 
or they may be made of metal supports with glass 
tops. They should be on casters, which will allow of 
their position being changed as often as is desired. 
The semicircular table devised by Dr. Halsted is con- 
venient, as it will hold the vessels containing the in- 
struments and dressings, while at the same time it 
hedges off the operator and his assistants from the 
bystanders. (Fig. 28.) One of two receptacles (made 
of iron or wire, which can be easily sterilized) for 
soiled dressings and sponges should be placed in the 
operating-room. 

An instrument-case, constructed somewhat like a 
book-case, for holding the instruments when not in use 
is a very necessary piece of furniture. It should be 
simply constructed, so as to permit of being easily and 
thoroughly cleaned. Those made of plain quartered 
oak are the most satisfactory. The wood should not be 
thick, and the shelves should be perfectly plain, without 
trimmings. The shelves are best made of light wood 
covered on the upper surface with a thin piece of glass, 
or they may consist entirely of wood or glass. They 
should be so arranged that any one of them can be 
pulled out separately, and the instruments be thus 
exposed without the necessity of touching them with 
the hands. (Plate XVI.) The instrument-case should 
be large enough to hold all the necessary instru- 
ments, and no cupboard should be placed beneath 



156 ASEPTIC SURGICAL TECHNIQUE. 

it, as it will render the case more difficult to clean and 
also increase the risk of contamination. It should have 
casters attached to it, so that its position can be changed 
as often as it is necessary to clean the floor beneath it. 

A good water-supply and conveniences for the disinfection 
of the hands are necessities in every operating-room, 
and an abundance of hot and cold water must be always 
at hand. Arranged on one side of the room there 
should be several marble basins, in order that the water 
may be changed rapidly and as frequently as is neces- 
sary. One or two large sinks will be necessary for 
cleansing the instruments and vessels between oper- 
ations, and these should contain the solution in which 
the glass dishes are immersed before a second operation. 
It will be better to have the basins with the attachments 
freely exposed, so that they can be easily kept clean. 
The glass vessels in which the hands are rinsed off 
during the operation should be placed on a small table 
close to the operator, and should contain either warm 
sterile water or salt solution. (Plate XVII., Fig. 3.) 
If glass basins are not obtainable, those lined with 
porcelain will serve every purpose. 

A table for holding the glass jars and glass dishes 
when not in use should occupy one of the corners of 
the room. It may be made of the same kind of wood 
as the instrument-case, and should be of the simplest 
possible construction. 

The sterilizers for filtered hot and cold water can be 
arranged at one end of the room, with the special 
enamelled pitchers belonging to them. 



PRIVATE OPERATING-ROOM. 157 

Stretchers upon which patients are moved from place 
to place in the hospital are of many kinds. The one 
which we have found to be most satisfactory is 168 cm. 
(66 inches) long, 56 cm. (22 inches) wide, and 87 cm. 
(34 inches) high. It may have either two wheels and 
two legs or four wheels. In any case the wheels should 
have rubber tires. The top should be detachable, that 
the patient may be carried about on it if desired. 

The operating-room of a private hospital can be arranged 
in very much the same manner as that belonging to a 
general hospital, but, of course, everything will be on 
a much smaller scale. So large a room will not be 
needed, as it will not be necessary to allow more space 
than that which is actually required for the fittings of 
the room and for those engaged in the work. The 
convenience of spectators will not have to be taken into 
consideration. The room should be situated in one of 
the upper stories, as far distant as possible from the 
other rooms of the house. One at the back of the 
house with a northern exposure, containing as many 
windows as possible, will be preferable on account of 
the light, and it will be a decided advantage if it have 
a skylight, which not only will give us light from 
above, but also can be opened after an operation and 
thus afford speedy and thorough ventilation. Two 
smaller rooms are better than a single large room, as a 
great many things which should not be in the oper- 
ating-room itself may be kept in the second room, 
which can communicate with it by a door-way which 



158 ASEPTIC SURGICAL TECHNIQUE. 

need have no door. The walls of the room should 
be painted with white enamel paint, as this can be 
washed without injury. The floor may be covered 
with linoleum, and this should extend up the walls of 
the room for one or two feet. The floor can then be 
thoroughly scrubbed without injuring either it or the 
ceiling of the room below. The fittings of the room 
should approximate as nearly as possible to those de- 
scribed for a large operating-room. The support for 
obtaining the Trendelenburg position can be obtained 
by the employment of the apparatus devised by Dr. 
George McKelway, of Philadelphia. The basins in 
which the hands are washed and sterilized should be 
conveniently situated. 

In order to have as much space as possible in the 
operating-room the doors should be made to open 
towards the outside. The same care is to be exercised 
in the cleansing of the room as with the operating- 
room in a general hospital, and once a week, as a 
matter of routine, it will be advisable to thoroughly 
scour the walls and the entire furniture. 

It is possible to arrange a small private operating- 
room at comparatively little cost. Time was when both 
operator and patient avoided hospital operating-rooms, 
as they seemed to be hot-beds of infection. Now, a 
surgeon will never operate, if he can avoid it, outside 
of his own well-regulated operating-room. However, 
even with the utmost care infection will sometimes 
occur, and too often a series of cases in which suppu- 
ration follows the operation are still met with. In 



PRIVATE OPERATING-ROOM. 159 

such instances the whole paraphernalia of the oper- 
ating-room, including instruments, furniture, ligatures, 
sutures, and dressings, are to be thoroughly overhauled 
and resterilized. There has been some fault in the 
technique, and, as all the good boys in the school suffer 
for one bad one, so everything in the operating-room 
must be resterilized in order that the one source of 
danger may not be passed over. 



CHAPTER XII. 

THE ORGANIZATION OF OPERATIONS — THE MAINTENANCE OF 
AN ASEPTIC TECHNIQUE DURING OPERATIONS. 

Now that we have completed the description of the 
preparation of the different materials which come into 
play in our operative technique, it may be well to de- 
scribe briefly the method of properly organizing oper- 
ations, whether major or minor, and to show how, after 
starting into surgical work with an aseptic field, ster- 
ilized instruments, hands, and dressings, the aseptic 
condition is to be maintained. 

In order to do the best work, the surgeon should sur- 
round himself with a sufficient number of well-trained 
assistants and nurses, and keep them with him for some 
time, until they have become used to his particular 
methods of working. No matter how well trained the 
individual members of the corps may be, the whole 
cannot move satisfactorily unless all have worked to- 
gether long enough for each to have learned his own 
particular duties and the precise relation of his own 
actions to those of others about him, so that his atten- 
tion may never be distracted. To borrow an expression 
from the foot-ball field, it is essential that the operator 
and his assistants shall do " good team work." It is 
necessary, therefore, in starting in to do regular oper- 
ative work in hospitals, large or small, that the surgeon 
160 



AN ASEPTIC OPERATION. \Q\ 

shall clearly define the exact duties of those about him. 
It is important that this shall he done at the start, and 
then, as experience in the course of time teaches, as it 
always does, that improvements in methods and in the 
distribution of duties can be made with advantage, the 
necessary changes may gradually be introduced. When 
a systematic routine has been once established, surgical 
work becomes a pleasure, and any operation can be 
done with but very few hitches and with a minimum 
of trouble. A surgeon who has accustomed himself 
to this orderly method of procedure will naturally avoid 
operations outside of his own operating-room, but will, 
nevertheless, in case the necessity arises, be the better 
prepared for conducting operations in private houses, 
or in other places where the dangers of breaking the 
technique become great. (Chapter XIV.) 

We shall proceed to describe, therefore, as a type, 
the order of events in an ordinary abdominal section, 
undertaken — let us say, for the removal of an ovarian 
cyst, of adherent adnexa, or for a hysterectomy — in a 
well-conducted operating-room. We shall suppose that 
the patient is a young and strong woman, of good con- 
stitution, in fair condition for operation, who has been 
under observation for some days, parts of which have 
been spent in bed, in order to accustom her to the re- 
cumbent position which will have to be maintained for 
a few days following the operation. She has had a 
general bath besides two antiseptic vaginal douches 
each day. A specimen of urine taken by the catheter 
has been carefully examined and has been found to 

11 



162 ASEPTIC SURGICAL TECHNIQUE. 

show no striking abnormalities. During this prelim- 
inary surveillance the diet has been limited to soft, 
easily-digested food, and the bowels have been kept 
freely opened. If abdominal hysterectomy is to be 
performed, especial attention must be paid during these 
days to the cleanliness of the vagina and cervix, inas- 
much as after removal of the uterus the dangers of 
infection of the peritoneal cavity from below are very 
great. The vagina in such cases must be repeatedly 
cleansed with soap and water and the douches be more 
frequent and thorough. Attempts to disinfect the cer- 
vical canal and the cavity of the uterus are perhaps in 
some cases justifiable.* 

The operation is to be done sharply at 9 a.m., an ex- 
cellent operating hour in a hospital. The day before 
the operation the patient's abdomen has been prepared 
in the way directed in Chapter IV., special attention 
having been given to the cleansing of the folds round 
the umbilicus. On the evening preceding the opera- 
tion a purgative has been administered, followed by 
an enema in the morning. The bladder has just been 
emptied by catheter, and the vagina, rectum, and ex- 

* One thorough method of doing this is to curette the internal sur- 
face of the uterus and cervix several days before the operation, and 
after curettement go gently over the surface of the uterine mucosa with 
the small point of the Paquelin cautery, packing the uterine cavity 
immediately afterwards with a strip of ten-per-cent. iodoformized 
gauze. The vagina is thoroughly douched twice daily and loosely 
packed with strips of iodoform gauze. Such radical measures are, 
however, only rarely to be adopted even in cases where the uterus is to 
be removed at the operation. 



AN ASEPTIC OPERATION. 163 

ternal genitalia have received a final thorough wash- 
ing. Nothing has been given by mouth since mid- 
night. The patient, attired in a fresh night-gown, 
flannel undervest, stockings, and warm wrapper, is 
now taken from the ward to the operating-room on 
a stretcher, where she should arrive at least half an 
hour before the time set for the operation. She is put 
to bed in a small room adjoining the operating-room, 
where an anesthetic will be given by one of the as- 
sistant surgeons. 

In the mean time the nurse has been doing her 
work. She is in operating-room garb, and her hands 
and arms have been thoroughly disinfected. She has 
consulted her instrument-list and has seen that every- 
thing is prepared and in good condition. The knives 
all have keen edges, and these and other things made 
of metal or rubber are boiling in a one-per-cent. soda 
solution. An abundance of sterilized gauze, sponges, 
dressings, and towels are ready. The temperature of 
the room has been properly regulated. 

The operating-table is prepared in the following 
way. A folded blanket or, better still, a felt pad, 
large enough to cover it, is placed upon the table. 
Over this is spread a rubber sheet, which in turn is 
covered with a fresh white sheet. The head of the 
patient is to rest upon a small hair-pillow or upon an 
air-pillow, and the rubber ovariotomy pad (Fig. 29) 
is placed in position. With the Boldt or some similar 
table this is not needed, as all fluids drain into a bucket 
placed beneath the table. 



164 ASEPTIC SURGICAL TECHNIQUE. 

Some surgeons prefer to employ the Horn-Martin or 
the Trendelenburg position for their operations. The 

Fig. 29. 




Rubber ovariotomy pad. (Kelly.) 

operating-table used by Martin is somewhat shorter 
than usual, and as the patient lies upon it the buttocks 
are placed near the edge and the legs are allowed to 
hang down. The surgeon sits on a chair between the 
patient's thighs, and is thus able to hold them steady 
without being obliged to support them. Besides the 
fact that the position is somewhat awkward, there is 
the objection that a larger incision is required in order 
to expose the pelvic structures than would otherwise 
be necessary. The advantages claimed for the table 
are (1) the facility given for making the first incision 
by the tension of the abdominal wall, (2) the inclina- 
tion given to the pelvis of the patient, by which the 
examination arid manipulation of the organs are ren- 
dered easier, and (3) the saving of fatigue to the 
surgeon, who is able to sit down during the entire 
operation. 

To Frau Horn, Dr. Martin's head operating-room 



AN ASEPTIC OPERATION. l(fi 

nurse, belongs the credit of suggesting a further im- 
provement in the construction of the table. A section 
of the middle portion of the top is so arranged that it 
can be let down, thus permitting the abdominal dress- 
ing to be applied with greater facility. 

The Trendelenburg position, in which the pelvis is 
elevated, has been considered to be of especial value 
in exposing the pelvic contents to view. While the 
patient is in this position the intestines are not so 
likely to obstruct the necessary manipulations, since 
by the action of gravity they are naturally displaced 
upwards towards the thorax. What would appear at 
first sight to be a somewhat serious objection to its 
adoption — namely, that it favors the spreading about 
among the intestines of any fluids that may be present 
in the pelvis, thus increasing the danger of the car- 
riage of septic material into the abdominal cavity — has 
been fully disproved by a mass of clinical and experi- 
mental evidence. 

The various basins which will be required are con- 
veniently arranged on the side tables. The sterilized 
salt solution and a plentiful supply of distilled water 
in large granite-ware vessels are being heated over 
Bunsen burners. When these matters have been at- 
tended to, the nurse gives her hands a second disin- 
fection, after which she must not touch anything 
which might contaminate them, and must leave it to 
the assistant nurse or attendant to do anything which 
necessitates the handling of unsterilized articles. 

The surgeon and his assistants have arrived in good 



166 ASEPTIC SURGICAL TECHNIQUE. 

time ; in their dressing-room they have removed their 
ordinary clothes, and have put on their operating-suits, 
they have entered the operating-room long enough 
before the operation to give themselves ample time to 
complete the disinfection of their hands and forearms. 
None of them should have been in contact with septic 
material for the forty-eight hours preceding. Any 
visitors who are admitted must be required to put 
on over their ordinary street clothing the long, loosely- 
fitting, freshly-washed linen dusters with which they 
have been supplied. 

Meanwhile, the anaesthetic has been started in the 
adjoining room, the assistant who has charge of it 
striving to so time it that the patient will arrive at 
the stage of surgical anaesthesia just when the surgeon 
has completed the sterilization of his hands and is 
ready to begin the actual operation. The partly- 
anaesthetized patient is now wheeled into the room on 
the stretcher, and lifted upon the table. There she 
may rest upon two pads, covered with muslin slips. 
These slips are changed between operations, the per- 
manent coverings of the pads being a waterproof 
rubber material. These pads lie side by side, with 
a narrow slit between them, through which the 
waste fluids may run to the drain provided for them 
on the table. The drain leads to a bucket at the 
upper end of the table. This bucket must be care- 
fully cleaned between operations, and when pus is 
encountered at the operation, a quart of 1-1000 bi- 
chloride of mercury solution should be placed in it. 
The patient's night-gown and undervest are rolled up 



AN ASEPTIC OPERATION. Mfi 

over the elbows to hold the arms still. The final dis- 
infection of the abdomen now takes place. The assist- 
ant nurse hands to one of the surgeons a basin of 
warm water, scrubbing-brush, and green soap, and 
the parts are once more thoroughly cleansed. The 
soapsuds are rinsed off with sterile water, and the 
surface of the abdomen is next sponged (sterilized 
gauze sponges being used) with ether or strong alco- 
hol. After a further washing with a one to one-thou- 
sand sublimate solution, the excess of sublimate is 
washed off with sterilized water or salt solution. 
Having now rendered the skin of the patient as nearly 
aseptic as possible, we try to keep it uncontaminated 
by covering the patient from shoulder to feet with 
sterilized towels arranged over the abdomen so that 
the field of operation can be exposed while at the same 
time the flanks are protected. Over the towels a large 
sterilized sheet is placed in position with an opening in 
the median line sufficiently large to permit of the neces- 
sary manipulations. Finally, the adjacent parts of the 
patient's body and of the operating-table are completely 
covered with sterilized towels, and the operation will 
be done through the artificial opening in the gauze 
over the abdomen. The assistant at the head of the 
table completes the anaesthesia, and the patient is 
ready for the first incision. 

The special duties of the different assistants and some 
other points are deserving of mention. The oper- 
ating-table is placed so that a good light shall, when 
the surgeon is in position, fall upon the field of oper- 



168 ASEPTIC SURGICAL TECHNIQUE. 

ation. The surgeon stands, of course, upon the right 
of the patient, and his first assistant stands opposite 
him upon the left side. The latter holds hemostatic 
forceps in his hand all ready to check the hemorrhage, 
and also attends to the sponging. 

In order to do the most satisfactory work, the sur- 
geon will require a liberal number of helpers. He 
should have, as a rule, three, four, or even five assistant 
surgeons, besides two nurses. Directly opposite him 
should stand the first assistant, and on either side of 
the table there should be an assistant. One of these 
should have the entire charge of the instruments and 
ligatures, while the other should look after the sponges 
and dressings which may be required during the oper- 
ation. The first assistant should help the operator 
directly, and, unless his hands are occupied in holding 
apart the structures or in other manipulations, the 
sponges and instruments should generally be passed 
to him. 

The assistant to whom the administration of the 
anaesthetic has been intrusted should give his undi- 
vided attention to this duty. 

A fifth assistant is of especial value if cultures have 
to be made or if any microscopical work is necessary 
during the operation. The head nurse in the oper- 
ating-room watches for any opportunity to be of service 
to the surgeon and his assistants. She must, as we 
have said, touch nothing which is not sterile, and 
indeed there is no necessity for her to contaminate her 
hands, as to the second nurse are relegated all duties 



AN ASEPTIC OPERATION. 169 

which involve the handling of any articles which have 
not been rendered aseptic. 

About the operation itself it is necessary to make 
here only a few general remarks. The special points 
are considered at length in other works in which the 
methods of the different abdominal operations are- 
discussed. The incision should be made in the median 
line with a sharp scalpel, starting midway between the 
umbilicus and the symphysis pubis, and being carried 
towards the latter. It should not, however, extend 
quite to the symphysis pubis, and care must be taken 
that the bladder shall not be injured. The first stroke 
of the knife cuts down to the superficial fascia. After 
the hemorrhage has been checked, this is divided ex- 
actly to the linea alba. Next come two fibrous layers 
between which is a variable amount of fat, after which 
there is a thin layer of fat directly above the perito- 
neum. The assistant should keep the parts clean by 
pressing a sponge firmly along the line of incision and 
then removing it quickly. The sponge is never to be 
rubbed along the line of the wound. After the tissues 
have been separated down to the peritoneum, this is 
lifted up with a pair of dissecting forceps. The as- 
sistant opposite the operator now with a second pair 
of forceps takes hold of another portion of the peri- 
toneum at a short distance from the first forceps, and 
while he raises it, the operator divides the peritoneum 
very carefully at a point between the two forceps. 
This precaution is necessary in order to avoid any 
possibility of injuring the intestines. At the moment 



170 ASEPTIC SURGICAL TECHNIQUE. 

the peritoneal cavity is opened air will enter, and the 
intestines, unless they are adherent, will fall away from 
the parietal peritoneum, making its further section 
free from danger. After the peritoneum has been 
divided for the full length of the incision through the 
skin, the abdominal structures are palpated with the 
left hand, and after a careful examination it will be 
possible to decide whether or not it will be advisable 
to enlarge the incision. If this is thought necessary, 
there should be no hesitation in doing so, as a better 
exposure will thus be obtained and all the manipula- 
tions will be much expedited. 

If cysts have to be punctured and evacuated, great 
care should be taken that none of the contents gain 
entrance into the peritoneal cavity, particularly if the 
cyst be papillomatous, since the fragments which es- 
cape may become implanted upon the peritoneum and 
give rise to malignant metatastic growths. Before the 
sac is punctured it is well to place a large sponge or 
piece of gauze round it, in order to absorb any fluid 
which we might otherwise not be able to catch. 
Should any fluid or particles of papillomatous growths 
in spite of our efforts have been carried into the ab- 
dominal cavity, they should be carefully sponged out. 
A collection of pus before being opened into must 
always be walled off from the peritoneal cavity. 

After the diseased parts have been excised and the 
pedicle firmly ligatured, the surgeon makes the peri- 
toneal toilette. If there has been no escape of fluid 
and no free oozing into the abdominal cavity, it is not 



AN ASEPTIC OPERATION. 171 

necessary to employ any irrigation, and it will be suffi- 
cient if the peritoneal cavity be sponged dry, particu- 
larly the portion posterior to the uterus. To do this 
the uterus is held well forward with the left hand, so 
that the sponges can be carried well down into the 
cul-de-sac. (Fig. 30.) All ligatures should now be 

Fig. 30. 




Sponging out cul-de-sac. 

well inspected before the ends are cut off, and, if there 
is little or no oozing and the pedicle does not retract 
from the ligature, the latter may be cut off about one 
centimetre from the knot. 

"When adherent structures are to be removed the 
technique to be carried out is more difficult than when 
they are free. It is in these cases that the larger ab- 
dominal incisions are required. Fortunately, adhesions 
are more rare now than of old, since patients submit to 



172 ASEPTIC SURGICAL TECHNIQUE. 

an operation earlier and the previous puncture of the 
abdomen for diagnostic purposes or for drawing off 
fluid is less common. If the intestines obstruct the 
field of operation, they can be kept out of the way by 
pushing them back and covering them with a large 
sponge or with a large piece of sterilized gauze wrung 
out of hot water or hot salt solution. The adherent 
structures are to be separated by gently working the 
adhesions loose with the fingers, every precaution 
being exercised in doing this to avoid any laceration 
of the abdominal organs, particularly of the intestines 
and bladder. If we find it impossible to separate the 
structures at any one place in this way, we proceed to 
make attempts to do this at various points until we 
find a point where the adhesions are less firm. This 
will frequently require considerable time, but it pays 
to " make haste slowly," since in the great majority 
of cases grave injuries can be thus avoided. If there 
should be much hemorrhage following such removal, 
it can frequently be checked by washing the peritoneal 
cavity with hot sterilized salt solution, or often, if the 
adhesions are fresh, simple pressure made with a ster- 
ilized sponge will arrest the bleeding. Where the 
adhesions are old and firm and the hemorrhage is 
persistent, the bleeding points must be ligated. In 
desperate cases of bleeding from the uterus, where all 
the ordinary means have failed, the hemorrhage can 
generally be checked at once by tying the ovarian or 
uterine arteries, or by packing the pelvic cavity with 



AN ASEPTIC OPERATION. 173 

ten-per-cent. iodoform gauze which has been wrung 
out after being dipped in very hot salt solution. When 
much oozing occurs over a large area, it may be con- 
trolled by sterile iron subsulphate or by the tip of the 
cautery (at a dull-red heat), applied lightly over the 
bleeding surfaces. 

The abdominal cavity is closed by first uniting the 
peritoneum by means of a continuous suture. (The 
question of drainage has already been discussed in 
Chapter VIII.) The skin and muscular surfaces are 
then brought together with deep sutures of silkworm- 
gut and silk. As a rule, we unite the fascia with 
buried Pagenstecker mattress sutures and the skin with 
a subcuticular catgut suture. If Halsted's subcutane- 
ous suture is employed, the stitching of the muscular 
and skin surfaces can be done separately. After the 
wound has been properly closed, we have to decide 
upon the most suitable method of dressing it. The 
following procedure has yielded very satisfactory re- 
sults. After the sutures have been tied, the incision 
and the immediate field of operation are cleansed with 
sterilized salt solution, followed by alcohol, after which 
they are gently dried with a sterilized towel. Over 
the site of the incision dry sterilized iodoform powder 
is sprinkled, over which come two thicknesses of steril- 
ized gauze and a sufficient quantity of sterilized cotton, 
so that not only the wound but the whole abdomen is 
thoroughly protected from the symphysis pubis to just 
above the umbilicus and from flank to flank. This 



174 ASEPTIC SURGICAL TECHNiqUE. 

dressing is held securely in place by means of strips 
of adhesive rubber plaster reaching from the unsteril- 
ized flank on one side to that of the opposite side. 
The whole is then covered with a sterilized scultetus 
bandage. This dressing in our hands has proved most 
satisfactory. We have found that even in the case of 
restless patients, who have moved about in bed a good 
deal, the wound has never been exposed on account 
of the slipping out of place of the dressing, and infec- 
tions of the skin have been very rare. For the occlu- 
sive dressing, formerly much employed, a strip of steril- 
ized gauze is placed over the incision and saturated 
with bichloride celloidin (p. 137), being covered in turn 
by a similar but wider strip, the second piece of gauze 
protecting a wide area of skin around the wound, while 
the first strip covers the incision itself. In ordinary 
cases the wound need not be disturbed for a week or 
more. When the dressing is to be removed, it will 
generally be necessary to moisten it thoroughly by 
applying to it for an hour a pad of absorbent cotton 
which has been soaked in sterile water or in a one to 
forty carbolic acid solution. If, however, we wish to 
remove it quickly and without causing pain, ether 
may be poured directly upon the dressing, which, as 
a rule, can then be readily removed. If the dressing 
still adheres to the stitches, we can cut them free from 
the gauze and remove them later. In removing the 
cutaneous sutures the loop is to be cut below the point 
where the celloidin and powders are encrusted, and at 
a point where the suture is moist and pliable. In this 



AN ASEPTIC OPERATION. 



175 



way we avoid dragging the ragged and rough part of 
it through its whole track. (Fig. 31.) The subcu- 
taneous suture probably has the advantage of lessening 
the chances of stitch-hole infection. After the stitches 
have been removed, the dry dressing of iodoform and 
boric acid powder (one to seven) or subiodide of bis- 
muth powder is applied to the wound. Over this it is 
better to place a piece of plain sterilized gauze, and if 



Fig. 31. 




Removal of the abdominal suture. A shows the suture in situ passing through 
skin, muscle, and peritoneum. CR, CR are the little masses of incrustation of 
hardened lymph discharged from the suture-track. B shows the removal of the 
suture, elevated and cut below the crust. C shows the direction in which it is to 
be pulled out. (Kelly). 

there is any tendency to separation of the edges of the 
wound it will be well to apply an additional strip about 
six centimetres (two and a half inches) in width over 
the surface, the whole dressing being kept in place with 
cotton and the many-tailed bandage. Dr. Halsted pre- 
fers to dress the wound of an abdominal section with 
strips of sterile gutta-percha tissue or leaflets of silver- 
foil, which are applied immediately along the line 
of incision, thus protecting the granulations which 
form ; he believes that the removal of ordinary dress- 



176 



ASEPTIC SURGICAL TECHNIQUE. 



ings into which the granulations have grown is very- 
injurious to the wound. In his dressings no powders 
or celloidin are applied, but pieces of dry sterilized 
gauze and cotton are placed over the protective, the 
whole being held in place by an abdominal bandage. 



Fig. 33. 



Fig. 32. 





Robb's leg-holder. 

Where the operation is to be upon the perineum, 
upon the vagina, or upon the uterus through the 
vagina, the external genitalia and adjoining parts will 
require more careful preparation. All the hair should 
be shaved off, and the parts should be thoroughly 



PLATE XVIII. 




Field of operation and the neighboring parts protected by gauze diaphragm, 

towels, and stockings. 



AN ASEPTIC OPERATION. 177 

scrubbed twice daily with soap and hot water for two 
or three days, and on the morning of the operation 
they should be thoroughly cleansed with alcohol and 
ether and afterwards with sublimate solution. The 
bladder and rectum are, of course, to be thoroughly 
emptied before this cleansing. The patient is anaes- 
thetized, brought to the operating-table, and placed in 
the dorsal position. The legs are flexed on the abdo- 
men, and may be conveniently held in place with the 
simple leg-holder shown in the figure. (Figs. 32 and 
33.) The external genitalia and the vagina are again 
scrubbed with soap and warm water, and the skin 
about the parts and over the thighs is irrigated thor- 
oughly with a one to one-thousand solution of sub- 
limate and afterwards with sterile water. The parts 
are then protected with a large piece of gauze, in 
which a hole is cut large enough to expose thor- 
oughly the perineum and vaginal outlet, and allow all 
the necessary manipulations. (Plate XXII.) If a con- 
tinuous stream of sterile water or salt solution be kept 
playing over the field of operation, sponging will be 
unnecessary and the operation will progress more 
speedily. 



12 



CHAPTER XIIL 

POST-OPERATIVE CARE — POSITION IN BED — DIET — VOMITING — 
RECTAL FEEDING — SHOCK — PAIN AND RESTLESSNESS — CON- 
STIPATION — CATHETERIZATION — CONVALESCENCE — REMOVAL 
OF STITCHES — DRESSINGS SUBSEQUENT TO OPERATIONS — HEM- 
ORRHAGE — INTESTINAL OBSTRUCTION — INFECTION. 

Immediately after the operation has been finished 
and the dressings have been applied, the patient, not 
yet completely recovered from the ansesthetic, is re- 
moved to the bed where she is to remain until 
convalescence. The after-care of operative cases is 
naturally of very great importance, and mistakes in 
treatment are often attended by the most serious 
results. The nurse in charge should be one who has 
had special experience in abdominal work, and none 
should be chosen who is not specially fitted for the 
post. At first the patient is to be kept quietly in bed 
in the recumbent position, and she must be closely 
watched until she has fully regained consciousness. 
Of the dangers from vomiting during the semi-uncon- 
scious stage it is scarcely necessary to speak. When 
it occurs, the head should be turned on one side and 
the nurse should have a basin ready to place beneath 
the patient's chin for the reception of vomited or 
mucous material, so that any soiling of the night- 
dress and of the bedclothes may be avoided. Every 
precaution must be taken to keep up the strength of 
178 



CARE AFTER OPERATIONS 179 

the patient and to keep her warm and comfortable. 
Exposure to draughts or allowing her to become 
chilled in a condition of lowered resistance may prove 
the exciting cause of a serious bronchitis or pneu- 
monia. Hot cans (Fig. 34) or hot-water bottles are 

Fig. 34. 




Hot-water can. 



to be placed around her in bed, care being taken 
that the skin shall not be burned. This may easily be 
avoided by placing a blanket between the can and the 
surface of the body. Neglect of this simple measure 
has before now led to serious superficial burns, which 
have delayed convalescence and have proved a source 
of much annoyance to both physician and patient. 

It is extremely difficult to lay down definite rules 
regarding the food and drink to be ordered after abdom- 
inal operations. Where a plastic operation has been 
performed upon the perineum and cervix, the problem 
is comparatively simple, and after the early nausea has 
disappeared a light soft diet may very soon be allowed ; 
but where the patient has undergone an abdominal 
section the greatest care has to be exercised. With 



180 ASEPTIC SURGICAL TECHNIQUE. 

ordinary simple cases a light soft diet may be given 
after the first twenty-four hours, but where the opera- 
tion has been a serious one, or where the viscera have 
been much disturbed, the woman must be kept as quiet 
as possible, and frequent feeding by way of the stomach 
cannot be permitted for some days. In all such cases 
a great deal of tact and patience will be required. Milk 
is not a good substance to give by the mouth after ab- 
dominal sections in the majority of cases. In the first 
place, it is not easily digested in the stomach, and the 
curd remaining may pass along the intestines and act 
as an irritant. In the second place, milk very often 
causes flatulence and produces much discomfort. Pep- 
tonized milk would be free from this objection; but 
patients, as a rule, complain of its bitter taste, and it 
is difficult to get them to take it more than once or 
twice. During the first six or twelve hours it will be 
found preferable, if there be any vomiting, to give the 
patient by mouth nothing except small quantities of 
toast- water or of warm water, from one to two teaspoon- 
fuls every fifteen or twenty minutes. This frequency 
of administration is generally not only tolerated, but is 
very comforting to the patient, from the fact that it 
tends to relieve the thirst which is complained of, and 
sometimes will diminish the vomiting as well. It will 
occasionally be desirable to give nutritive enemata at 
intervals of three or four hours. They should not be 
given more frequently than this, for fear of rendering 
the rectum intolerant of them. The enema should 
consist of milk with whiskey or brandy, together with 



DIET AFTER OPERATION. 181 

the white of an egg and a little common table salt. 
The following proportions make a good combination, 
and the enema may be given by means of a hard-rubber 
syringe or through a rectal tube. 

R Peptonized milk, 30 cc. (^i) ; 
Whiskey, 30 cc. (gi) ; 
The whites of two eggs ; 
Common table salt, 1.5 (grs. xxiv). 

The rectum should be thoroughly irrigated once or 
twice daily with warm physiological salt solution, which 
will keep it clean, so that the nutritive enemata will be 
better absorbed. 

Often, besides the warm water and toast-water, fifteen 
or twenty drops of sherry with one or two teaspoonfuls 
of soda-water, given at frequent intervals, will be re- 
tained by the stomach. This method of treatment can 
be kept up for the first day or so. After this, if the 
patient is still willing to take a fluid diet and there is 
no vomiting, the quantity of the liquids may be gradu- 
ally increased. At the end of the third day we may 
begin with small quantities of milk and lime-water by 
the mouth, if the patient cannot take the peptonized 
milk. It is better to give this in the proportion of 
two parts of milk to one part of lime-water, slowly 
increasing the quantity of the former each day and 
diminishing the amount of the latter until the patient 
is taking three parts of milk to one part of lime-water. 
It is unwise to give cold water to drink to quench the 
thirst, and the custom of allowing the patient to suck 



182 ASEPTIC SURGICAL TECHNIQUE. 

ice is not a good one, as neither is nearly so efficacious 
as warm water, and the patient is never satisfied, hut is 
always asking for more. Besides this, the ingestion 
into the stomach of much cold water or ice soon causes 
nausea, and may thoroughly upset the stomach and 
thus add considerably to the discomfort of the patient. 
If she still complains of distressing thirst, an enema 
consisting of five hundred cubic centimetres (one pint) 
of tepid water may be slowly administered. This may 
be repeated if necessary, and is generally most satis- 
factory in its results. If the patient does not vomit 
at all or only at infrequent intervals, after some six 
or twelve hours, home-made beef-tea or beef-jelly, in 
teaspoonful doses, either concentrated or diluted, may 
be given. 

The above treatment applies to those cases which 
proceed easily and rapidly towards recovery. When, 
however, the vomiting is persistent and aggravated, it 
becomes a most troublesome symptom, and one which 
taxes severely the ingenuity of the surgeon and of the 
nurse. The vomiting which follows anaesthesia may 
sometimes be relieved by allowing the patient to rinse 
out the mouth with warm water, a procedure which 
will often help to relieve the thirst, which is at times 
almost unbearable. While the nausea and vomiting 
continue, the head should rest on a level with the 
body or be only slightly elevated on a small pillow. 
As a rule, the vomiting due to the anaesthetic is over 
by the end of eighteen or twenty-four hours, and when 
this symptom continues after the third day, and par- 



VOMITING AND SHOCK. 183 

ticularly where the fluid is expelled without much 
apparent effort, in too many cases peritonitis is to be 
feared. After the second or third day, if there still 
be a great deal of nausea, it may sometimes be relieved 
by giving two or three tablespoonfuls of very hot water 
containing from twenty-four to thirty centigrammes 
(four or five grains) of bicarbonate of sodium to thirty 
cubic centimetres (one ounce) of water. This may 
be repeated every hour or so, and where it does not 
succeed, a mustard leaf may be applied over the epi- 
gastrium. In a certain number of cases the wash- 
ing out of the stomach may be of service. 

The vomiting which accompanies a marked septic 
condition, such as a general or a localized peritonitis, 
is, however, most resistant to treatment. In the ma- 
jority of cases this symptom is aggravated instead of 
being relieved by the administration of drugs especially 
directed against it, and the treatment of the accompa- 
nying constipation or tympany is more likely to stop 
the vomiting. Occasionally (but only as a last resort) 
it may be necessary to give a hypodermic injection of 
morphine over the epigastrium for the relief of the 
severe retching, if there is reason to fear that it will 
otherwise soon exhaust the patient. 

In those cases where the operation has been a long 
one, or where the viscera have been much disturbed, it 
becomes necessary to employ unusual methods of stim- 
ulation to tide the patient over the stage of shock until 
she reacts. Into the question of the true nature of 
" shock" and the phenomena of " reaction" we shall 



184 ASEPTIC SURGICAL TECHNIQUE. 

not go now. What little is known about them can be 
obtained from the text-books on general surgery. The 
treatment may be briefly outlined as follows. The 
patient should be kept warm ; she should be enveloped 
in blankets, and hot-water cans or hot sand-bags should 
be applied round the trunk and thighs and to the soles 
of the feet. Stimulating applications may be cautiously 
made over the epigastric region, and if necessary the 
legs and forearms may be enveloped in cloths wrung 
out of hot water ; while in alarming cases hypodermic 
injections of ether, brandy, whiskey, or camphor are 
given every few minutes or every half-hour, according 
to the urgency of the symptoms. 

Nearly every patient is restless and suffers more or 
less pain during the first twenty-four hours after an 
operation. Not every complaint must be met with 
drugs, and a skilful nurse can do much to relieve many 
of the little discomforts of which the patient com- 
plains. A slight change in position, made by putting 
a soft pad or pillow under the head and shoulders or 
under the bend of the knees, so that the legs are sup- 
ported in a flexed position, will often do much to effect 
this. The arms, legs, and chest may be sponged with 
warm alcohol or with soap and warm water. After the 
first day, if the patient is still restless and there is no 
contra-indication, it will do no harm to transfer her 
once in the twenty- four hours from one bed to another 
which has been already prepared and dressed with 
warm clean linen. This, if done in the evening, very 
often succeeds in giving the patient a good night's 



THE USE OF MORPHINE. 185 

sleep. Convalescence is promoted also by frequent 
spongings and by rubbing the body with alcohol. If, 
in spite of our efforts, the patient continues to be very 
restless, especially at night, the administration of an 
enema consisting of three or four grammes (48 to 64 
grains) of bromide of potassium with from fifteen to 
thirty cubic centimetres (Sss to Si) of milk of asa- 
foetida may be tried, and if necessary repeated in 
an hour or two. If the restlessness still persists, 
or if the patient suffers severe pain, it may be neces- 
sary to give morphine in doses of from ten to six- 
teen milligrammes (^ to \ grain), which may be re- 
peated according to the effect produced. Morphine, 
however, should never be used unless all other meas- 
ures fail. It is much better to encourage the patients 
to control themselves and to bear the pain, telling 
them that it will not last long, and that they will be 
in every way much better if they can endure it for 
a short time longer without taking medicine for its 
relief. The routine employment of morphine is to be 
condemned. The healing always proceeds better with- 
out it, and there is little doubt that the surgeon is 
often directly responsible for the formation of the mor- 
phine habit. Unfortunately, the practice of giving this 
drug as a matter of course after operations is apparently 
becoming more and more wide-spread. It is popular, 
perhaps, because it affords immediate comfort to the 
patient and to the surgeon. It is not an infrequent 
practice of surgeons to keep their patients under the 
influence of morphine for the two or three days subse- 



186 ASEPTIC SURGICAL TECHNIQUE. 

quent to the operation. Its use is occasionally a neces- 
sity, but in the vast majority of cases I feel sure that a 
patient does not require any sedative at all after an 
operation, especially if we enlist on our side her own 
moral support. The danger of using morphine after 
operations lies in the fact that after a short time the 
patient not only feels the necessity of its repeated use, 
but is also much more difficult to manage ; she becomes 
restless and fretful, complaining loudly of the most 
trivial suffering, and her morale suffers so much that 
at times her mind becomes unbalanced. In the after- 
care of over one thousand coeliotomies, only in rare 
instances have we found it necessary to give a dose 
of morphine, and even then in some of the cases in 
which it was given there was more than once occa- 
sion to regret its employment. 

In the majority of cases it is well that the bowels 
should be opened on the second or third day after an 
abdominal operation. The giving of medicines by the 
mouth for this purpose is often contra-indicated, es- 
pecially in the cases in which there is much nausea. 
The most satisfactory method consists in the adminis- 
tration on the second day of an enema consisting of 
five hundred cubic centimetres (one pint) of soapsuds 
and warm water, given as high up as possible. To do 
this, the rectal tube having been introduced well up 
into the rectum, to the external end a small glass 
funnel is attached ; the mixture of soap and water 
is poured into it and allowed to run slowly into the 
bowel. Sometimes a litre can be introduced in this 



TREATMENT AFTER OPERATION. 187 

way. If the enema has not been effectual, it may be 
repeated after three or four hours, or an enema may 
be given consisting of warm water, oil, and turpentine 
in the following proportions : 

Plain warm water, 500 c.c. (Oj) ; 

Olive oil, 60 c.c. (gii) ; 

Turpentine, from two teaspoonfuls to a tablespoonful. 

This may be repeated once or twice at intervals of two 
or three hours, but generally the first enema is fol- 
lowed by a satisfactory evacuation of the bowels. If 
preferred, the first enema may consist of from one 
hundred and twenty to one hundred and eighty cubic 
centimetres (Siv to Svi) of warm olive oil or glycerin, 
to soften any fecal matter that is in the rectum, and 
an hour or so later it may be followed by a second 
made of soapsuds and warm water. Sometimes an 
enema consisting of a pint of warm soapsuds and 
water mixed with thirty grammes (3i) of Epsom salts 
will act where others have failed. If, however, there 
are no contra-indications to the giving of medicine by 
the mouth, in addition to using the enema we may give 
by mouth about one-third of a bottle of the efferves- 
cent citrate of magnesium, to be repeated every two 
hours until the bowels have been opened. Some, 
again, prefer a Seidlitz powder to be taken on the 
second morning after the operation, and in other cases 
it may be advisable to give calomel in doses of from 
ten to thirty milligrammes (£ to J grain) every two or 
three hours at night, to be followed by a Seidlitz powder 



188 ASEPTIC SURGICAL TECHNIQUE. 

on the next morning. The compound liquorice powder 
is a favorite laxative with some surgeons. 

If the employment of these measures fails to pro- 
duce an evacuation of the intestinal contents, the ex- 
istence of an obstruction of the bowels is to be sus- 
pected, and the question of resorting to operative 
measures has to be considered. 

After the bowels have been thoroughly opened the 
patient may complain of a feeling of weakness, and 
sometimes, indeed, there is a considerable degree of 
prostration. In order to counteract this condition it 
may be necessary to give a warm enema containing a 
stimulant, one consisting entirely of peptonized milk 
with the addition of brandy or whiskey being often 
very useful. After plastic operations upon the peri- 
neum it is, of course, absolutely necessary that there 
should be no straining at stool, and after each move- 
ment the parts must be carefully cleansed, on account 
of the danger of infection. 

Catheterization of the patient at stated intervals after 
an operation is advised in most of the text-books. 
This procedure is, however, by no means always 
necessary. As a rule, the urine need not be drawn 
off for at least six or eight hours, if this is done im- 
mediately after the operation before the patient leaves 
the table. It is a good plan to wait until the patient has 
expressed a desire to micturate, and has been allowed 
to attempt to void her water voluntarily without suc- 
cess before employing the catheter. If she is encour- 
aged to try to pass her urine, in some instances cathe- 



TREATMENT AFTER OPERATION. 189 

terization will not be necessary at all. During the 
first twenty-four hours the secretion of urine is» scanty, 
and it would therefore seem unnecessary to draw it 
off more frequently than every six or eight hours. 
The troublesome cystitis which sometimes follows 
catheterization may generally be avoided by the ex- 
ercise of the proper precautions, as we have already 
shown in an earlier chapter. (Chapter X.) In plastic 
cases it is particularly important, of course, that cathe- 
terization be done aseptically and that the field of 
operation be not irritated by urine. 

In every case for a certain time after an abdominal 
section the patient should remain in the recumbent 
position as much as possible. The maintenance of 
such a position, of course, is particularly desirable if 
the drainage-tube has been employed, lest the struc- 
tures be injured or the tube displaced. After the first 
ten or twelve hours immediately following an ordi- 
nary abdominal section, if there is no contraindica- 
tion, the patient may with safety be placed on her side 
for a few minutes at a time, while the back is sup- 
ported by pillows. This, indeed, may often be per- 
mitted even earlier, if the drainage-tube has not been 
used and if the patient has vomited but little. The 
change of position from the back to the side, if it adds 
to the comfort of the patient, may be made every two 
or three hours during the day and night. While the 
patient is lying on her side the back and legs may be 
well rubbed with alcohol, after which the bed will not 
feel so uncomfortable when the dorsal position is re- 



190 ASEPTIC SURGICAL TECHNIQUE. 

sumed. As a rule, the patient should not be allowed 
to sit up in bed until the sixteenth or eighteenth day 
after an abdominal operation, and even then the first 
attempts should be limited in duration to a few min- 
utes, and should not be made without the use of the 
bed-rest to support the back and head. Gradually 
the time may be prolonged, until at the end of the 
third week the patient may be allowed to get out of 
bed ; but on the first day she should simply be wrapped 
in a blanket and placed in a rolling- or rocking-chair 
for ten or fifteen minutes, and at the expiration of 
this time should be put to bed again. On the next 
day, if the first getting up has not tired her too much, 
she may be allowed to sit up a little longer ; and on 
the third day the time may be extended to an hour or 
perhaps more, and increased every day until she can 
sit up all the morning and finally during the entire 
day. About the end of the fourth week she may be 
allowed to walk, but only for a few steps at a time. 
She should, however, avoid going up- and down-stairs 
and lifting anything for some days. The observance 
of these precautions is important, for if they are 
neglected many patients will subsequently complain 
a great deal of the backache and general weakness 
which often follow a too early getting about. Before 
the patient is permitted to get out of bed she should 
be furnished with an abdominal bandage (Fig. 35), 
which not only will tend to prevent any opening of 
the incision, which might be followed by a hernia, but 
will also add a great deal to the patient's comfort by 



TREATMENT AFTER OPERATION. 191 

supporting the abdominal walls. This bandage should 
be used for from six months to a year. After it has 

Fig. 36. 




Abdominal bandage. 

been worn for about three weeks it need not be kept 
on during the night while the patient is lying quietly 
in bed. 

After a trachelorrhaphy or a perineorrhaphy has been 
performed the patient is generally allowed to sit up in 
bed with the bed-rest or supported by pillows on the 
tenth or twelfth day, and on about the seventeenth day 
after the operation she may get out of bed. Any inter- 
nal stitches may be removed at the end of the third 
week, and the patient can then begin to walk around 
slowly, provided that she is very careful not to do too 
much and is particularly cautious in going up and down 
the stairs. After an operation upon the perineum the 
patient should keep in the recumbent position for the 



192 ASEPTIC SURGICAL TECHNIQUE. 

first ten hours. After this, if she is restless and com- 
plains of pain in the back, or if she desires to change 
her position, she may be carefully turned on her side. 
A small soft pillow should be placed between the knees. 
A bandage around them will seldom be necessary, 
as the patient can generally be induced to keep the 
knees sufficiently close together, and if she is told to 
keep the internal surface of one as nearly as possible 
opposite to that of the other, there will usually be no 
harm done by dispensing with the bandage. The T 
bandage which is applied over the line of the wound 
will sufficiently protect it from any injury of the parts 
which might otherwise be caused by movements that 
the patient makes in turning over. As a rule, after 
the first two or three days the patient may assume the 
position which she finds most comfortable. 

In ordinary section cases where the abdomen has 
been closed without drainage, the stitches may be re- 
moved on the seventh or eighth day. Some of the 
precautions to be observed when removing the stitches 
have already been referred to in Chapter XII. Natu- 
rally, the hands are to be disinfected whenever a wound 
is being cared for. After the removal of the stitches 
the incision should be protected by some sterile non- 
irritating material, such as gauze impregnated with 
iodoform, or sterilized cotton, or else a powder consist- 
ing of iodoform and boric acid (one to seven) may be 
dusted freely over the parts. Over this, again, some 
sterile cotton may be applied and held in place by 
a many-tailed bandage. This dressing need not be 



TYMPANITES. 193 

changed more frequently than once every two or three 
days, or until the wound becomes dry, after which it is 
only necessary to place a strip of sterile cotton over the 
line of incision, which can usually he dispensed with 
after the third week subsequent to the operation. 

After a trachelorrhaphy or a perineorrhaphy has 
been performed about two drachms of sterilized iodo- 
form are dusted into the vagina. A strip of sterilized 
gauze is inserted, but is removed within twenty-four 
hours after the operation, and, as a rule, need not 
be reapplied. Over the external wound iodoform and 
boric acid powder (one to seven) or subiodide of 
bismuth powder may be applied, and gauze and cot- 
ton held in place by a T bandage, which must be 
changed as often as it becomes soiled. The bandage 
and external dressing will generally not be required to 
protect the parts after the external stitches have been 
removed. 

Tympanites, a by no means uncommon symptom fol- 
lowing abdominal operations, is most frequently caused 
by constipation, and in that case is usually relieved 
when the bowels are evacuated. It may give rise to 
severe pain, and, by causing pressure upon the dia- 
phragm, often embarrasses the action of the heart and 
lungs and leads to acceleration of the pulse and res- 
piration. One or two drops of the tincture of capsi- 
cum in a teaspoonful of warm water every half-hour 
for three or four doses, or fifteen to twenty drops of 
the essence of peppermint, will prove an effectual 
remedy for the more simple cases. At the same time 

13 



194 ASEPTIC SURGICAL TECHNiqUE. 

a mustard leaf or a warm application, such as a turpen- 
tine stupe, may be applied over the epigastrium, care 
being taken not to leave it on long enough to cause 
a blister. If the tympanites still continues after the 
bowels have been well opened, it will be well to pass a 
rectal tube, which has been previously well warmed 
and oiled, into the bowel for a distance of fourteen 
inches, and thus get rid of the accumulated gases. 

Hemorrhage, and especially intra-peritoneal hemor- 
rhage, will rarely be met with after operations, if the 
technique of the surgeon has been good. When, 
however, it does occur, and the loss of blood is consid- 
erable, the condition may soon become serious. The 
symptoms which follow such an accident must always 
be carefully watched for after any abdominal operation. 
The lips grow pale, the face takes on a fixed expres- 
sion, the pupils are dilated, the surface of the body 
soon becomes covered with a clammy sweat, the ex- 
tremities are cyanosed, and the patient complains of 
dizziness, or even loses consciousness. When the hem- 
orrhage is extensive, the only hope lies in reopening 
the wound and ligating the bleeding vessels. Hemor- 
rhage following stitch-hole wounds seldom assumes 
any serious proportions. 

Peritonitis, by which we mean an infection of the 
peritoneum either local or general, is always an unfor- 
tunate complication. Not every case of tympanites 
with distention is due to peritonitis. It is only when 
one gets the array of symptoms which form so striking 
a clinical picture — the pain, the distention, the drawn 



PERITONITIS. 195 

expression of the face, the pinched look about the 
nostrils, and the wiry pulse — that one is justified in 
positively diagnosing an acute peritonitis. Of stitch- 
hole infection we need not speak here, except to point 
out that the elevation of temperature which accompa- 
nies it does not usually appear before the second week. 



CHAPTER XIV. 

OPERATIONS IN THE COUNTRY, IN PRIVATE HOUSES, OR IN 
OTHER PLACES WHERE THE TECHNIQUE MUST NECESSARILY 
BE MORE OR LESS IMPERFECT — THE ARMAMENTARIUM — AN 
IMPROVISED OPERATING-ROOM — MODIFICATIONS IN TECH- 
NIQUE. 

Every time that a surgeon is called upon to operate 
at a distance from the hospital or from his regular 
operating-room, he has to encounter many difficulties 
in the way of maintaining asepsis. It is, however, just 
under these circumstances that the well-trained op- 
erator who has mastered the principles underlying 
surgical technique will he ahle to utilize this knowl- 
edge while adapting himself to his surroundings. 
Even if he is called upon to operate on the shortest 
notice he need never be taken by surprise, and even if 
the conditions are the most primitive, so long as he has 
fire, water, and vessels, he is in a position to carry out 
an aseptic technique. Boiling water will give him 
sterile instruments, ligatures, and dressings, — though 
there are other and better ways of obtaining these, — 
and it will be possible for him to regulate his sur- 
roundings with a fair degree of satisfaction to himself. 

A surgeon who is frequently called upon to do oper- 
ations away from home will find it convenient to have 
a set of instruments, dressings, and other necessaries 
196 



THE ARMAMENTARIUM. 197 

already packed in a transportation valise, or to have 
these kept apart and always sterile, so that they can he 
put together in a few moments. The instruments and 
all the dressings should he rendered sterile in the same 
manner as when preparing them for operations in the 
hospital. The materials that are required can he sup- 
plied from the regular stock in the operating-room. 
If one has not the advantage of an operating-room 
supply to draw upon, then it will he well to furnish a 
room adjoining the office, so that the materials can he 
kept in good order after they have once been sterilized. 
Before going to an operation the instrument-list should 
he consulted, and one must be particularly careful to 
make sure that nothing that will be required is left 
out, since away from home it will not be possible to 
make a requisition upon the stock instrument-case for 
any article which has been forgotten. The surgeon 
should give the preparation of the outfit his personal 
attention, or intrust it to a trained assistant or nurse 
whom experience has proved to be competent. For 
many reasons it is better to sterilize the instruments 
and dressings at the place where the operation is to be 
performed, in which case it will be necessary to take 
along the small soda solution apparatus (Chapter V.) 
and an Arnold steam sterilizer. If for some reason or 
other this is impossible, they may be sterilized before 
the surgeon sets out, and afterwards conveyed to the 
place of operation under aseptic precautions. If the 
instruments are to be sterilized after arriving at the 
house, they can conveniently be carried arranged in 



198 



ASEPTIC SURGICAL TECHNIQUE. 



compartments in a long sheet of canton flannel, which 
is then rolled up and tied round the middle with a 



Fio. 36. 




Canton-flannel sheet for instruments. 



broad tape. (Figs. 36 and 37.) If they have been 
sterilized at home, they may be carried in stout ster- 
ilized bags made of butcher's linen, and closed by a 
draw-string. It will be found convenient to have 
several sizes of these bags, so that the more bulky in- 
struments may be kept in the larger and the knives and 
forceps in the smaller ones. Three or four hard-rub- 
ber trays for the instruments should be included in the 
outfit, and should be made so that they may fit into one 
another ("nests"), and thus not occupy too much room. 
A box made of nickel and shaped like a telescope valise 
is a good instrument-holder. Sterilized nail-brushes 
may be rolled up in a sterile towel or carried in a well- 
stoppered jar containing carbolic acid solution. Good 



THE ARMAMENTARIUM. 



199 



soap in tin cases, and air-tight screw-capped bottles con- 
taining potassium permanganate and oxalic acid, and 
a good supply of green or oleine soap must not be for- 
gotten. The sterilized gauzes, cotton, sponges, and 
bandages are best rolled up in sterilized towels and 
enclosed in sterilized gauze or bags. It will be better 
to have at the operation a few wide-mouthed sterilized 
glass jars which hold from one-half to two litres and 

Fig. 37. 




-ir t- T 1 C 



% 

Instruments wrapped in canton-flannel sheet. 

are fitted with air-tight covers. The ligatures are 
carried in the large ignition tubes, which are plugged 
with cotton stoppers and have been sterilized in the 
manner before described. Several tubes may be care- 
fully rolled up in a towel. The outfit should include a 
liberal supply of towels, rubber gloves, and mackin- 
toshes. 

It is well to collect everything before commencing to 
pack the valise, so that each item on the list may be 



200 ASEPTIC SURGICAL TECHNIQUE. 

checked off as the article is put in. The " telescope" 
valise will be found most serviceable and convenient. 
It has also the advantages of being inexpensive and of 
being easily cleaned, and things packed in it can be 
transported safely. The surgeon who has many out- 
side calls will find it very convenient to have two or 
three bags always ready, one containing the necessary 
instruments for abdominal sections, a second those re- 
quired for the ordinary plastic cases, and a third those 
employed in the simpler operations, such as dilatation 
and curettement. 

In handling the articles and preparing the outfit it 
is essential, if they are sterilized, that the person who 
does this shall prepare his hands and forearms as care- 
fully as if for an operation. 

The inside of the valise, particularly the lower half, 
should be well protected with sterilized towels or with 
a piece of muslin sufficiently large to be folded entirely 
over the contents after they have been put in. In pack- 
ing the glass-ware great care should be taken to avoid 
breakage upon the journey. 

In order still further to preclude the possibility of 
any contamination during transportation, we can wrap 
the bags containing the instruments, cotton, towels, 
and trays in a piece of sterilized rubber mackintosh. 
After the valise has been well packed and the top has 
been properly adjusted, it should be fastened snugly 
with the leather straps. 

The operating-room should be chosen with special 
regard to two requirements, — viz., (1) that it is well 



THE OPERATING-ROOM. 201 

lighted, and (2) that it can he easily cleaned. To 
select it, if possible, an assistant or nurse should 
be sent to the house a few days before the opera- 
tion. The nurse, besides, should be with the patient 
for two or three days, in order that all the neces- 
sary preparations may be made. In case this is 
impossible (for example, in the country and in the 
practice of another physician), special instructions 
should be sent several days previously, in order that 
everything may be ready. The room chosen is to be 
cleared of all the ordinary furniture, carpets, and rugs ; 
the floor and, if possible, the walls and ceiling should 
be thoroughly scrubbed with soap and water. All 
hangings are to be removed from the windows and 
doors, and special attention is to be given to the 
cleansing of the window-sills, of all corners and crev- 
ices, and of the wood-work generally. For the oper- 
ating-table, an ordinary plain, narrow kitchen-table 
will answer every purpose. It should measure about 
three feet in length, thirty inches in height, and 
twenty-two inches in width. For the patient's feet to 
rest on, a plain wooden chair can be placed at the end 
of the table at such an angle that the back of the 
chair will be caught under the lower edge of the table. 
It will be necessary to have two other tables about the 
same size as the operating-table, on which the ves- 
sels which are to contain the instruments, ligatures, 
sponges, and other necessaries may be placed. When 
the same sort of tables as the operating-table cannot 
be obtained, any two small, narrow tables about the 



202 ASEPTIC SURGICAL TECHNIQUE. 

house may be used for this purpose, provided that, 
after being thoroughly scrubbed with soap and water 
and bichloride solution, they are covered with sterile 
towels. Six perfectly plain wooden chairs should also 
be ready ; plush or cane-seated chairs are not suitable 
for this purpose. The tables and the chairs should be 
thoroughly scrubbed with soap and water and mopped 
over with a one to five-hundred aqueous solution of 
bichloride of mercury. After this preparation they 
are not to be touched until the surgeon and his as- 
sistants arrive. There should be an abundant supply 
of hot and cold water, which, after being boiled, 
should be kept ready for use in perfectly sterile ves- 
sels. Special orders must be given about the cleans- 
ing of the large tin boilers in which the water is to 
be kept. They should be thoroughly scrubbed out 
with sand-soap and water and then well rinsed out 
with water. The water which is to be employed 
for washing the hands and instruments should be 
thoroughly boiled some hours previous to or even on 
the day before the operation. The supply vessels 
in the operating-room should be provided with lids, 
which should be covered with sterilized towels or 
some other clean material, in order to avoid the 
slightest risk of contamination from the dust of the 
room. On the day of the operation one of the boilers 
should be placed on the stove and a sufficient quan- 
tity of water made hot again. The water should 
remain under the supervision of an assistant, to 
whom the duty of attending to the bringing of it 



PREPARATIONS FOR OPERATION. 203 

to the operating-room should be delegated. It will 
not be safe to allow one of the members of the 
family or a servant to undertake this duty, as they 
might, from ignorance, be guilty of putting their 
hands into the pitcher, or in some other way might 
contaminate the water. Four or five perfectly clean 
china basins and pitchers, which have been thoroughly 
scrubbed out with soap and water and then rinsed out 
with one to five-hundred bichloride solution and plain 
hot water, will be needed to receive the hot and cold 
water, being afterwards covered with sterilized towels. 
The preparation of the patient in a private house can 
be as thorough as in a hospital, and the methods 
already advised in Chapter IV. should be closely fol- 
lowed. Where possible, the surgeon will find it best 
to have two nurses, one who will attend to the prepa- 
ration of the patient and will have the subsequent 
charge of the case, and a second to attend to the 
details of the operating-room and to assist at the op- 
eration itself. If the operation be in the country, the 
surgeon should always have at least one assistant with 
him, who has had the advantages of a practical train- 
ing in modern methods, to aid him in the maintenance 
of an aseptic technique. This is particularly advisable 
for abdominal work; and if an untrained assistant is 
permitted to take any part in the operation, he must 
be thoroughly instructed as to what he is to do, and 
that he is to touch nothing unless especially told to do 
so. The nurse and the assistant should make as little 
noise as possible while arranging the room in which 



204 ASEPTIC SURGICAL TECHNIQUE. 

the operation is to be performed. The assistant should 
allow himself at least two or three hours in which to 
make his preparations. When he arrives at the house, 
the nurse should be called, and she should at once 
show him to the room. He first proceeds to clean his 
hands, and then, having dressed himself in his uni- 
form, begins his work. The tables and chairs are put 
in their places, the operating-table occupying a posi- 
tion near a window from which the greatest amount 
of light will be thrown upon the field of operation. 
Those on which the vessels containing the instruments 
and sponges are to be placed are arranged at a conve- 
nient distance from it. The sterile water, which has 
been boiled some hours previously and allowed to cool, 
must be ready. The hot water which is in the boilers 
on the kitchen stove should be transferred to the clean 
pitchers by means of a perfectly clean tin ladle with a 
long handle, the tops of the pitchers being immediately 
afterwards protected with a towel or a gauze hood, and 
strict orders being given that under no circumstances 
is any one to put his hand into the water or touch the 
mouth of the pitcher. I have not infrequently seen 
both nurses and doctors test the temperature by dipping 
their fingers into the water in the pitcher. This, of 
course, is an inconsistency, and should not be per- 
mitted. 

After these preparations have been made, the assist- 
ant proceeds to wash his hands and forearms before 
getting the instruments ready. If, however, he wears 
the rubber gloves and rinses them well in a one to 



PREPARATIONS FOR OPERATION. 205 

five-hundred bichloride solution from time to time, 
it will not be necessary to give the hands the final 
scrubbing until later. The basins or trays, after be- 
ing washed out with a one to five-hundred aqueous 
solution of bichloride of mercury and then with hot 
water, are now partially filled with the plain hot 
water and are ready to receive the instruments and 
ligatures. The artery forceps should all be placed 
in one tray, and the ligatures and needles in another, 
while a third is devoted to the scalpels and scissors 
with the dissecting forceps which are first used at 
the beginning of an operation. Two large basins half 
filled with plain sterile water should be provided, 
the first in which the sponges can be cleaned and the 
other in which they are kept. On the table nearest 
the operator should stand two basins filled with plain 
hot water, so that he may rinse his hands from time 
to time during the operation. There should be near 
at hand a vessel in which the diseased structures which 
are to be removed can be received. The assistant 
now takes off the rubber gloves and then thoroughly 
disinfects his hands. The gloves can be placed in the 
basin containing the bichloride solution and put on 
again if it is necessary for him to help to lift the patient 
on the table. The patient should not be anaesthetized 
until everything has been satisfactorily arranged, so 
that there may be no delay after she is once ready. It 
may be left to the assistant who has charge of making 
these preparations to say when the anaesthetic is to be 
administered, as he knows exactly how long it will take 



206 ASEPTIC SURGICAL TECHNIQUE. 

to complete them. The operator should arrive at least 
fifteen minutes or half an hour before the time set for 
the operation, and should spend this time in changing 
his clothes and in cleansing his hands. A nurse or one 
of the assistants should be ready to change the water in 
the basins for him. The nurse generally remains with 
the patient while the anaesthetic is being administered. 
This is best given in a room away from the operating- 
room, as the patient will then not be disturbed by the 
noise or by the sight of the preparations. The anses- 
thetizer will require aid in carrying the patient to the 
operating-room and placing her in position on the table. 
If the other assistant surgeons help him to do this, 
they should wear rubber gloves and armlets. 

The patient being on the table, the abdomen is first 
thoroughly cleansed in the manner previously de- 
scribed. This cleansing should be performed by one 
of the assistants who is well acquainted with the method 
which the operator employs for this purpose. While the 
abdomen is being prepared, the second assistant, who 
has been scrubbing his hands for the last time, should 
soak them thoroughly in the one to five-hundred bi- 
chloride solution for one or two minutes, and then rinse 
them off in the plain sterile salt solution or hot water 
just prior to the beginning of the operation. The ab- 
domen having been rendered sterile and the field of 
operation being protected with the gauze and towels, 
the operator is ready to make the first incision. 

If irrigation of the abdominal cavity is required, a 
pitcher which has been thoroughly sterilized should 



IRRIGATION. 207 

be ready. The most convenient vessel for this is a 
glass jar, the so-called thermometer-jar, to which refer- 
ence was made on page 132. If an ordinary pitcher 
is to be used, a sterilized thermometer is necessary in 
order to test the temperature of the water, as it will not 
be safe to trust to the impression given to the hand 
from the outside, and it will not be allowable to place 
the fingers in the water. 

It requires a considerable length of time to arrange 
all the details that have been described, but if we hope 
to do an aseptic operation none of them can be neg- 
lected. Where, from the grave condition of the pa- 
tient, it is necessary to operate immediately, of course 
it will be impossible for us to carry out all these details, 
but in any case we should attempt to follow them as 
closely as possible. Naturally, even where the most 
careful and elaborate preparations are made, there are 
many more chances for the wound to become contami- 
nated than there would be in an operating-room es- 
pecially set aside for the purpose. We must, however, 
never fail to pay strict attention to the details, since, 
though we may have good luck for a while, careless 
habits, once formed, cannot fail sooner or later to lead 
to bad results. 

In doing plastic operations a rubber irrigating-bag 
filled with warm sterile water, suspended from a nail 
driven into the sash of the window, may be used, by 
means of which a steady stream can be directed upon 
the parts, thus doing away with the necessity for 
sponging. Not so much furniture will be required 



208 ASEPTIC SURGICAL TECHNIQUE. 

for a plastic as for an abdominal operation. One 
table is generally sufficient for holding the vessels 
containing the instruments and ligatures. On a chair 
on the left-hand side of the operator a basin may be 
placed to receive the soiled instruments. These should 
never be allowed to touch his lap, unless it is protected 
by a piece of sterilized gauze or a sterilized towel. 
On another chair to the right of the operator may be 
placed a tray for holding the instruments that will be 
required throughout the operation. Not only does 
this simplify matters a good deal, but the instruments 
run less risk of becoming contaminated. 

The after-care of cases has been outlined in Chapter 
XIII. If the operator lives too far away to make it pos- 
sible for him to see the patient every day, he must of ne- 
cessity intrust her to the care of a local physician, leav- 
ing with her, if possible, one of his own trained nurses. 
Before going away he must not omit to give full in- 
structions regarding diet, catheterization, the adminis- 
tration of enemata, and the indications for changing 
the dressings, and to provide as far as possible against 
any emergency which may arise. 

A detailed description of all the possible chances of 
error and of the many precautions which must be 
taken to meet them would require the writing of a 
whole book. In this chapter we have attempted 
merely to give an outline of the general course to be 
pursued, leaving it to the good sense of the surgeon 
himself to decide upon the precise steps to be taken 
when other emergencies arise. 



CHAPTER XV. 

ANESTHESIA AS AN AID TO DIAGNOSIS: ITS IMPORTANCE IN 
GENERAL SURGERY AND GYNAECOLOGY — PREPARATION OF 
PATIENT — POSITION — METHODS OF EXAMINATION — RECTAL 
PALPATION. 

"When making a physical examination of the abdo- 
men in obscure cases where the existence of some 
deep-seated tumor or abscess, or, in fact, any patho- 
logical condition is suspected, it is often impossible 
under ordinary circumstances to obtain satisfactory re- 
sults. Sometimes palpation is so painful that the 
patient cannot endure the slightest manipulation, and 
even when no pain is present, not only in nervous 
patients but in others as well, we find that as soon as 
the hands touch the abdomen, the muscles, more 
especially the recti, at once become so tense, in spite 
of all the patient's efforts to assist us, that it is impos- 
sible to feel anything which may be beneath them. 
Besides this we have to take into account the possi- 
bility of the existence of a so-called "phantom" 
tumor. 

It is not now considered a serious matter to put 
a patient under the influence of an anaesthetic, and 
consequently, where after a preliminary examination a 
reasonable doubt still exists, it has become much more 
common to make a further examination under anses- 

14 209 



210 ASEPTIC SURGICAL TECHNIQUE. 

thesia. In this way we not only spare the patient any 
unnecessary pain, but all the muscles of the body are 
relaxed, and thus the conditions most favorable for 
palpation are obtained. This aid to diagnosis, it is 
true, has not been sufficiently appreciated or employed 
often enough by surgeons ; and even in many of the 
larger clinics of to-day this method is but rarely used. 
The advantages which it presents, I think, must be 
quite evident even in general surgery, but it is in 
gynecological cases in which after a careful internal 
and external examination doubt still exists concerning 
the condition of the pelvic organs that the best results 
can be obtained by its employment. I shall there- 
fore confine myself to speaking briefly of its use in 
gynaecological cases. 

Without the administration of an anaesthetic it is 
impossible in the majority of cases to arrive at an 
absolutely correct idea of the condition of the pelvic 
organs. Of course, it should be the rule to examine 
first in the usual manner, but if doubt still exists as 
to the exact condition of the uterus and its appendages, 
this first examination should be supplemented by a 
second, during which the patient should be under 
complete narcosis. In this way mistaken diagnoses 
can often be corrected, and doubts can be cleared up. 
In the majority of instances small adherent tubes and 
ovaries cannot be definitely outlined until the patient 
is fully anaesthetized; not infrequently, on the other 
hand, cases come before us in which the clinical his- 
tory has suggested the presence of pelvic inflammation, 



ANESTHESIA IN DIAGNOSIS. 211 

so that we are predisposed to believe that an abnormal 
condition of the pelvic organs exists, which requires 
operative treatment, whereas an examination under 
anaesthesia will convince us that the structures are 
healthy, and that we must look for some other cause 
to explain the symptoms. Cases again in which the 
clinical history and the preliminary examination have 
suggested nothing, so that no serious pathological con- 
dition of the parts was suspected, have proved, when 
the patient was under complete anaesthesia, to be in- 
stances of adherent lateral structures. 

In two hundred and forty cases which came under 
my charge, in each of which two examinations were 
made, one in the ordinary way and the second with 
the patient under complete anaesthesia, precisely simi- 
lar results as to the condition of the adnexa were 
obtained from the two examinations in only eleven 
cases. In fifty-one cases, even after complete narcosis, 
the adnexa of both sides could not be definitely out- 
lined. It was possible to make a diagnosis in one 
hundred and eighty-one minor cases and in fifty-nine 
abdominal cases. 

While it is true that it is often possible to palpate 
the pelvic organs in women who have borne children 
without the use of an anaesthetic, this rule is by no 
means without exceptions, and in a number of cases, 
which have been examined, even under complete an- 
aesthesia it was not possible to state definitely that the 
uterine appendages were free from disease. 

Any one who has had much experience in the ex- 



212 ASEPTIC SURGICAL TECHNIQUE. 

animation of cases under anaesthesia has no doubt 
found this to be true in a certain proportion of cases, 
and the statement not infrequently made that a skilled 
gynaecologist should always be able to determine 
whether disease of the pelvic organs exists by an ex- 
amination under anaesthesia must be considered in- 
correct. 

Although, however, we cannot in every case make 
a certain diagnosis, yet it is evident that such exami- 
nations, if carefully made, will certainly diminish the 
number of exploratory incisions. This by itself would 
be a decided gain, as every operator knows that such 
procedures are not entirely free from danger, and are 
often much dreaded by the patient. In many cases 
also, patients will not be subjected to unnecessary 
operative measures, while, on the other hand, many 
will be restored to health by the early recognition of 
the existence and by the removal of diseased structures. 
Even in cases where an abnormal condition of the 
pelvic organs calling for operation is known to be 
present, it is often of great importance that the sur- 
geon should before operating have as complete infor- 
mation as possible about the existing lesions. Thus 
an examination under anaesthesia would in some cases 
show beforehand the probable value of an operation, 
and since the danger is so slight I believe, that such a 
preliminary examination should be employed unless 
any clear contra-indication is known to exist. 

It should be a practice, then, after the history of the 
patient has been taken, to examine the pelvic organs 



ANESTHESIA IN DIAGNOSIS. 213 

in the usual manner. If the structures cannot be 
satisfactorily outlined, an examination under anaes- 
thesia should be advised, after which a rational mode 
of treatment can be outlined. Where disease of the 
pelvic organs has been suspected and nothing abnor- 
mal is detected, the patient will be relieved of any 
anxiety which she may have felt in regard to her con- 
dition. At the same time the physician can satisfy 
himself as to the necessity for, or the disadvantages of, 
an immediate operation, and much of the routine treat- 
ment, which is to a great extent empirical, may then 
be omitted. We can also with good conscience dis- 
pense with the prescribing of the multitude of drugs 
which have been so highly vaunted for imaginary 
pathological conditions of the pelvic structures, and 
trust rather to hygienic measures, or, in case it is 
necessary, proceed at once to an operation. 

I shall now speak more in detail of the methods 
to be employed in making an examination under 
anaesthesia. 

In preparing a patient for the examination, the fol- 
lowing rules are to be observed. The alimentary 
canal should contain as little food as possible, so that 
it is well to have the bowels of the patient well opened 
the day before, and again on the morning of the ex- 
amination. The patient's diet the night preceding 
should be light, and the breakfast on the day of ex- 
amination should consist of a glass of milk or a cup 
of tea or coffee. If, however, the patient can be in- 
duced to do without even this, there will be less nausea 



214 ASEPTIC SURGICAL TECHNIQUE. 

and vomiting subsequent to the anaesthesia. The 
anaesthetic is generally administered about two or 
three hours after the breakfast hour. The clothing 
of the patient should consist of a light wrapper or 
night-dress, which should be so arranged that it will 
not hinder the examiner. Complete anaesthesia is 
necessary, as it is often impossible to palpate the 
structures thoroughly if there is the slightest resist- 
ance. Again, the diagnosis must not be made from 
the first impression that one gets of the condition of 
the structures when making an examination under 
complete anaesthesia, for often that which at first 
seems to be an unusual condition of the pelvic organs 
is found, after a more thorough examination, to be 
normal. For these reasons anaesthetics which act 
quickly and have but a transitory effect should not be 
used. 

The position of the patient is of great importance. 
During the examination she should lie across the 
mattress or on a table, so that the buttocks rest on 
one edge, the legs being separated and flexed on the 
thighs, which are in turn flexed on the abdomen. In 
this position the abdominal walls are well relaxed. If 
it is impossible to have the legs supported by assist- 
ants, the leg-holder can be employed. After the patient 
has been placed in position, a sheet is arranged over 
the lower extremities so that they are covered. (Plate 
XIX.) The external genitalia are first inspected. 
It is best to adopt a certain order in the examina- 
tion. Beginning with the vagina, and passing thence 



H 




■ J 



METHODS OF EXAMINATION. 215 

to the cervix, one next endeavors to palpate the uterus 
and its appendages, and afterwards the ureters. The 
urine having been drawn off with a sterile glass cathe- 
ter, the index finger or, more commonly, the index 
and the middle finger, previously anointed with vase- 
line, are introduced just within the vulva, and we 
endeavor to ascertain whether any laceration or cica- 
tricial tissue exists at the orifice or along the vaginal 
wall. The hand is then turned so that the palmar 
surfaces of the examining fingers come in contact 
with the anterior vaginal wall. The lateral walls and 
fornices are next examined, and the existence in the 
vagina of any viscid or abnormal secretion is noted. 
We next come to the cervix, and note (1) the position 
which it occupies with relation to the axis of the va- 
gina; (2) its shape and consistence, whether it is coni- 
cal or flattened, soft or hard ; (3) whether it is lacer- 
ated, and the extent of such lacerations if they exist ; 
(4) whether there is any eversion of the lips. The 
bimanual method of examining the uterus and its 
appendages is the most satisfactory. The operator 
places his right hand on the abdominal wall of the 
patient midway between the umbilicus and the sym- 
physis pubis, his forearm being flexed at the elbow, 
the fingers (with the nails cut close) extended, the 
hand slightly flexed at the wrist-joint. Pressure 
should be made obliquely downward in a line running 
towards the tip of the coccyx, thus avoiding the in- 
testines as much as possible. The hand in the vagina 
is now gently but firmly pushed upward towards the 



216 ASEPTIC SURGICAL TECHNIQUE. 

hand on the ahdominal wall, in order to palpate the 
structures which are being depressed by the external 
hand. If the appendages are difficult to palpate, and 
the uterus is in retroposition but not adherent, the 
examination may be facilitated by bringing the uterus 
forward. If the uterus will not stay in anteposition 
without support, it can be kept in this position by 
pushing it towards the symphysis pubis with the 
fingers of the abdominal hand. Starting from the 
uterus, one passes gradually to the side, making 
deep pressure with the fingers on the abdomen, and 
allowing them slowly to rise again, making the fingers 
in the vagina follow as closely as possible the fingers 
of the other hand as they move. In this way each 
portion of the broad ligament is passed between the 
fingers, so that there is less likelihood of missing the 
ovaries, or of overlooking any abnormality that may 
exist connected with the appendages of the uterus. 

The mere palpation of the adnexa in itself is not of 
very great service. In order to make a definite diag- 
nosis, each structure must be definitely and precisely 
outlined before we can be certain of the presence or 
absence of pathological conditions. 

If a satisfactory examination cannot be made by the 
combined vaginal and abdominal manipulation, then 
palpation by the rectum may be employed, either alone 
or in combination with the abdominal and vaginal 
touch. The examination is made by introducing the 
first or second finger of the left hand into the rectum ; 
often, however, both are employed. If one finger 



RECTAL PALPATION. 217 

only is introduced into the rectum, the other may be 
inserted into the vagina, while the fingers of the other 
hand press the abdominal wall obliquely downward. 

Immediately after the examination the patient is 
given a vaginal douche of a litre of a warm aqueous 
two-per-cent. solution of carbolic acid. As soon as 
she recovers from the effects of the anaesthetic, she is 
allowed to return home, but is advised to remain in 
bed for at least two or three days. Of course great 
care must be taken during the examination never to 
handle the structures roughly, as a cyst or other sac, 
if present, is liable to be ruptured, and a fatal result 
might possibly ensue. 



CHAPTER XVI. 

BACTERIOLOGICAL AND CLINICAL EXAMINATIONS IN SURGERY 

AND GYNECOLOGY. 

It has already been stated that the principles under- 
lying the technique which modern surgeons employ 
are based upon the brilliant results of bacteriologi- 
cal investigation. The importance of a practical ac- 
quaintance with the methods of bacteriology has also 
been fully insisted upon. Although for an intelligent 
knowledge of these methods the text-books devoted 
especially to this science must be consulted, it has 
nevertheless been thought worth while to devote a 
few paragraphs here to the subject of the outfit which 
will be required for the ordinary work of the investi- 
gating surgeon, and at the same time to refer briefly 
to some practical points which may be of service. 

To become the owner of all the apparatus described 
in the books as necessary for bacteriological work 
would of course be beyond the power of most sur- 
geons, and indeed all the items are by no means neces- 
sary. It is surprising what an amount of good bac- 
teriological work can be done with a very meagre 
outfit, — a thermostat, a sterilizer, a microscope with 
an oil immersion lens, a few test-tubes, and a small 
quantity of platinum wire. 

A good microscope with an Abbe condenser and an 

218 



BACTERIOLOGICAL EXAMINATIONS. 219 

immersion lens is indispensable. The supply of cul- 
ture media kept on hand need not be large. Tubes 
of agar-agar and gelatin will be most necessary, while 
a few of bouillon, blood-serum, potato, milk, and lac- 
tose-agar will be convenient at times in differentiating 
bacteria. The surgeon or the assistant who does the 
bacteriological work should himself assume the re- 
sponsibility of the preparation and sterilization of the 
media. If this is neglected, of course no reliance can 
be placed on the results. The hot-air sterilizer and 
the thermostat (kept by the thermo-regulator at 37° 
C.) need not be large. For ordinary work a gelatin 
thermostat (at 22° C.) may be dispensed with, and 
gelatin plates may be allowed to grow out at the room 
temperature. For the making of plates the Petri 
dishes are very convenient and are now not expensive. 
In case, however, they are not at hand, the " Esmarch 
plates" may be made by rolling the inoculated tubes 
on a block of ice. 

In making bacteriological examinations a certain 
definite routine should be followed. In the first place 
smear cover-slip preparations should be made from 
the material to be examined. These should be dried, 
fixed in the flame, and stained with one of the ordi- 
nary bacterial dyes (anilin oil gentian-violet, carbol- 
fuchsin, or Loffler's methylene blue). The study of 
these will give an idea of the varieties and number of 
micro-organisms present. At the same time plate 
cultures should be made, usually with dilutions, and 
the different varieties, if more than one be present, 



220 ASEPTIC SURGICAL TECHNIQUE. 

should afterwards be isolated in pure culture. Each 
variety is then carefully studied as to its morphologi- 
cal and cultural characteristics, and if necessary by 
inoculation into animals. The identification of micro- 
organisms is often tedious and difficult, and the work 
should, where possible, be done under the control of 
an experienced bacteriologist. The growing of the 
organism on the different kinds of culture media, the 
examination for motility, the enumeration of the 
flagella in specimens stained especially to demonstrate 
them, and the determination of spore formation are 
points which should not be neglected where such pre- 
cision is necessary. The animals best suited for bac- 
teriological tests are mice, rabbits, and guinea-pigs. 
The first are preferably inoculated subcutaneously at 
the root of the tail ; in the case of rabbits and guinea- 
pigs the material to be experimented with may be 
placed either under the skin or into the peritoneal 
cavity, while in the case of the former intravenous 
injections are also sometimes employed. When an 
animal has died from an experimental infection a 
careful autopsy should be made upon it; the gross 
appearances of the various organs should be noted, 
and frozen sections, cover-slip preparations, and plate 
cultures should also be made from them, the report 
of such examinations being recorded in neatly kept 
protocols. Most of the anaerobic bacteria can now be 
easily cultivated, since Buchner's jars have been intro- 
duced. Such bacteriological work when carefully 
done is sometimes of the greatest value, but when per- 



BACTERIOLOGICAL EXAMINATIONS. 221 

formed in a careless or slipshod way is likely to do 
far more harm than good. 

Bacteriological examinations are often very helpful 
in diagnosis ; thus, for example, gonorrhoea and tuber- 
culosis may often be diagnosed from the cover-slip 
preparations of the discharge alone. Instead of making 
the ordinary cover-slip preparations, a very convenient 
method consists of smearing the material directly over 
a large area of a glass slide. After the preparation 
has been allowed to dry in the air the slide is passed 
through the flame, and the staining is then done in 
the ordinary way. The excess of stain having been 
washed off, the slide is dried between folds of blot- 
ting-paper. A drop of oil is then placed directly 
upon the smear, no cover-glass being employed, and 
the preparation is examined immediately. The same 
method may be employed where it is necessary to 
examine several different specimens at one time, the 
smears being made at different spots on the same glass 
slide and all stained at once. 

Culture media, platinum needles, and clean cover- 
slips should always be ready in the operating-room, so 
that everything shall be on hand in case at an oper- 
ation it should be desirable to make cultures from an 
abscess or from the contents of a cyst. 

In the controlling of the disinfection of the skin, 
and of the methods employed for the sterilization of 
suture materials and dressings, methods of procedure 
similar to these just described should be resorted to. 
It is, of course, to be remembered that, where the 



222 ASEPTIC SURGICAL TECHNIQUE. 

germicidal effect of chemical solutions — as, for exam- 
ple, in dealing with the disinfection of the skin — is 
being tested, care is to be taken that none of the chemi- 
cal substance is carried over into the culture medium, 
or the whole experiment will be vitiated. The erro- 
neous conclusions previously held in regard to the 
disinfectant power of corrosive sublimate had their 
origin in faulty technique. 

At an autopsy on a patient who has died after an op- 
eration a thorough bacteriological examination should 
be made, for it is only in this way that any adequate 
conception is to be gained of the peculiar forms which 
infections can assume. Here, too, cover-slip prepara- 
tions and cultures are to be made from the organs, 
and animals are to be inoculated with portions of the 
tissues. This triple precaution might at first seem un- 
necessary, but often one method will succeed when 
others fail. Thus not infrequently the number of 
micro-organisms present is so small that they are not 
seen in the examination of smear cover-slip prepara- 
tions, and yet a few colonies may nevertheless grow 
out in the plate cultures. Again, in the case of an 
organism like the micrococcus lanceolatus, which may 
be hindered from developing in the tubes from some 
slight fault in the culture media, it might perhaps be 
isolated with ease from the blood of a susceptible 
animal which had been inoculated with a piece of the 
tissue containing it. On the other hand, where the 
organisms are already dead, as not infrequently hap- 
pens in old-standing pelvic abscesses, cultural methods 



CLINICAL EXAMINATIONS. 223 

and inoculation experiments would of course fail to 
demonstrate the presence of any bacteria at all, while 
simple cover-slip preparations will often show the dead 
bacteria. Finally the staining of tissues, which have 
been hardened in absolute alcohol, according to the 
method of Gram as modified by Weigert, or with 
methylene blue and eosin, should be resorted to as 
still another method of control. 

More will be said later upon the examination of 
tissues from a pathological stand-point. 

Clinical Examinations. — It is not necessary to offer 
an apology here for insisting on the importance in 
surgical and gynaecological cases of making thor- 
ough clinical examinations. The specialist to be 
successful in the truest sense of the word must be 
a man who has first laid a broad foundation of 
general medical knowledge before attempting to de- 
vote himself more exclusively to the study of the 
diseases of some special part of the body. But the 
rank and file of the specialists of to-day number 
among them very many who, seeking a royal road 
to knowledge and perchance to fortune, have thought 
to build a durable superstructure upon a flimsy basis. 
Much of the opprobrium against specialism is attrib- 
utable to the narrowness of such men who have never 
striven to gain a varied clinical and pathological ex- 
perience, and consequently are entirely lacking in the 
unbiased judgment which such a training alone can 
bring. The uterus and the ovaries, like the eye, the 
nose, and the throat, are only parts of the organism. 



224 ASEPTIC SURGICAL TECHNIQUE. 

The gynaecologist who blames his fellow practitioner 
for diagnosing a case of salpingitis as one of typhoid 
fever has perhaps not examined the urine of a patient 
suffering from a diabetic pruritus whom he is himself 
treating. 

The gynaecologist should be a well-trained clinician, 
and, while he cannot perhaps be expected to keep 
abreast of the general medical literature, he should at 
least be well acquainted with all those conditions 
which are not infrequently associated with disturb- 
ances of the female genital organs. And in order 
to be able to exclude serious organic disease in his 
patients and to guard himself against resorting to a 
serious operation upon an individual whose general 
condition, if it were recognized, would forbid such a 
procedure, he will take pains to secure a thorough 
training in general medical and surgical diagnosis. 
The importance of examining into the state of the 
emunctories in surgical cases is recognized by all, 
and skill in the different physical, chemical, and micro- 
scopical manipulations necessary is essential. 

The urine in every case — certainly in those which 
require operation — should be carefully studied, and 
records kept as to the color, odor, reaction, specific 
gravity, and the presence or absence of albumen, 
sugar, or bile. The sediment collected by allowing 
the specimen of urine to stand for some time in a 
conical glass (or more quickly by centrifugalization) 
should be examined microscopically, and the occur- 
rence in it of any casts, cylindroids, crystals, cells, or 



CLINICAL EXAMINATIONS. 225 

other substances should be noted. In special cases it 
may be desirable to determine the toxicity of the 
urine. Where pyuria exists the pus should be ex- 
amined bacteriologically. 

The examination of the blood by the newer hema- 
tological methods will often throw light on obscure 
cases in surgical and gynaecological practice. By this 
we mean not simply the noting of the general char- 
acteristics, but a fuller and more complete examina- 
tion, — the careful study of the "fresh-blood slide," 
the estimation of the haemoglobin, the counting of the 
red and white elements, and the study of specimens 
dried and stained according to the methods of Ehrlich. 
The relation of chlorosis to menstrual troubles has 
long been known and taught, but there is probably 
no more common mistake made than to treat locally 
the amenorrhoea of chlorosis instead of attempting to 
improve the blood condition. 

The presence or absence of an acute leucocytosis in 
the blood has often been found of great importance in 
the diagnosis of inflammatory and suppurative con- 
ditions within the pelvis as well as elsewhere in the 
body. The ready way in which the existence of a 
malarial infection may be recognized or disproved by 
the examination of specimens of fresh blood cannot 
fail to be of service in differential diagnosis. Un- 
doubtedly patients suffering from genuine chronic 
malaria have before now gone the rounds of the 
specialists and submitted to varied local treatment 
without avail, while on the other hand it is to be 

15 



226 ASEPTIC SURGICAL TECHNIQUE. 

feared that more than once a localized abscess with its 
chills and intermittent fever has been classed as a case 
of malarial fever by the medical attendant. 

The study of the sputum, too, will often prove a 
valuable aid. The importance of the early recogni- 
tion of pulmonary tuberculosis can hardly be over- 
estimated, and, strange as it may seem, this task often 
falls within the province of the gynaecologist, for it is 
to him that these patients frequently come first, com- 
plaining of weakness, disinclination for exertion, amen- 
orrhcea, or other menstrual irregularities. 

The giving of a test breakfast and the abstraction 
and subsequent examination of the stomach contents 
may give valuable indications not for diagnosis alone, 
but also for treatment. The enormous strides made 
of late years in these chemical examinations and the 
clinical deductions which may be drawn from them 
are fully appreciated by the teachers of modern in- 
ternal medicine, and there is no reason why surgical 
and gynaecological patients should be denied these 
benefits. In all cases in which there are symptoms 
referable to the stomach and in which the passing of 
a tube is not contraindicated, a test breakfast should 
be given and the stomach contents studied. The 
quantity, reaction, and appearance should be noted, 
the total acidity estimated by titration, the presence 
or absence of free acid demonstrated with Congo red, 
and of free hydrochloric acid by means of the phloro- 
glucin-vanillin reaction. Besides this, the presence 
or absence of the lab-ferment (by the fresh milk test), 



CLINICAL EXAMINATIONS. 227 

of lactic acid or lactates (by Uffelmann's test), and the 
activity of the digestive power on egg albumen should 
be determined. In some instances additional points 
of value in the differential diagnosis of abdominal 
tumors may be gained by the electrical illumination 
of the stomach. 

The chemical and microscopical examination of the 
faeces, too, will often help us in the management of 
difficult cases. 

The importance of paying close attention to the 
primae visa in all surgical cases cannot be too much 
insisted upon. In healthy digestion and normal ab- 
sorption lie the main secrets of that shadowy " resist- 
ance" about which we talk so much and know so 
little. Our more recent knowledge upon the subject 
of the auto-intoxications and auto-infections from the 
gastro-intestinal tract must be constantly borne in 
mind and applied by every surgeon who would have 
his wounds do well. 

Other things being equal, that surgeon will make 
fewest mistakes and obtain the best results who knows 
how to utilize to the utmost the knowledge and tech- 
nical methods of all departments of medical science. 



CHAPTER XVII. 

THE EXAMINATION OF THE INTERIOR OF THE FEMALE BLADDER, 
AND THE CATHETERIZATION OF THE URETERS. 

Until recently a lack of convenient and satisfactory 
methods for the examination of the interior of the 
bladder has impeded the progress of vesical and 
ureteral therapy. The older ways of inquiring into 
diseased conditions of the more remote portions of 
the urinary passages were wholly inadequate. The 
cystoscope of Mtze and Leiter, and the endoscope 
of Grtinfeld, while affording, indeed, to a trained 
specialist a view of a part of the bladder at one time, 
were entirely unsuitable for use in general practice; 
and the catheterization of the ureters, as recom- 
mended by Simon and subsequently by Pawlik, was 
too complicated a procedure to permit of more than a 
very limited application. General practitioners, and, 
perhaps, the majority of specialists, were content to 
base their diagnosis, prognosis, and treatment upon 
conclusions drawn from the subjective symptoms of 
the patient supplemented by the results of a careful 
examination of the urine. Fortunately, Dr. Kelly* 
and others have so extended and at the same time have 
so simplified the technique of the examination of the 



* The American Journal of Obstetrics, 1894, vol. xxix., No. 1. 
228 



CATHETERIZATION OF URETER. 229 

bladder and ureters that the field is practically open 
to all, and there seems to be no reason why the 
methods which, without the use of complicated ap- 
paratus, permit of direct visual inspection of the whole 
female bladder and ureteral orifices, and which render 
it possible to complete the catheterization of both 
ureters within a few seconds after the introduction of 
the" speculum, should not, like laryngoscopy and oph- 
thalmoscopy, be taught to students in every medical 
school. 

The following instruments are required for the 
examination : One female catheter of small calibre ; a 
urethral calibrator graduated in millimetres ; a series 
of urethral dilators ; a series of specula with obtura- 
tors; an ordinary head-mirror, with some artificial 
light, best supplied by an electric lamp ; one pair of 
long, delicate mouse-toothed forceps; a suction ap- 
paratus for completely emptying the bladder; a ure- 
teral searcher, and. a flexible silk ureteral catheter. 

The patient is catheterized, and a small pledget of 
cotton soaked in 10 per-cent. solution of cocaine is 
introduced into the urethra. In ten minutes this 
will have produced complete numbing in that region. 
The vulva is then carefully cleaned up, just as for the 
operation of D. and C, and the patient is placed in the 
knee-chest position. The size of the external meatus 
having been determined by the calibrator, the dilator of 
the corresponding size is first introduced, and is fol- 
lowed in turn by the larger ones of the series until the 
urethra is dilated to a diameter of from twelve to 
fifteen millimetres, or a little more than half an inch. 



230 



ASEPTIC SURGICAL TECHNIQUE. 



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232 ASEPTIC SURGICAL TECHNIQUE. 

The necessary degree of dilatation can usually be 
completed without more than a slight external rup- 
ture, and when it has been reached a speculum of the 
same size as the last dilator is introduced and the 
obturator belonging to it is removed. By means of 
the knee-chest position, the pelvis is elevated from 
eighteen to twenty inches above the table. This 
manoeuvre causes the bladder to balloon out with 
air. (Plate XX.) The examination is made with 
the aid of the head-mirror and artificial light. A 
candle in a dark room suffices if no other light is avail- 
able. The obturator being withdrawn from the specu- 
lum, the bladder immediately becomes distended with 
air, and by properly directing the reflected light it be- 
comes possible to examine every portion of it. There 
is usually, even after the most careful catheterization, 
a little residual urine, which can be removed by the 
suction apparatus, or, if the amount be trifling, by 
means of little balls of absorbent cotton held in the 
long mouse-toothed forceps. After a little practice on 
the normal bladder, the operator becomes acquainted 
with the distribution of blood-vessels in the mucous 
membrane, and with certain landmarks which enable 
him to recognize without difficulty the sites of the 
ureteral orifices. Thus, on elevating the handle of the 
speculum, so that the base of the bladder comes into 
view, the region of the inter-ureteric ligament becomes 
visible. This is often to be distinguished by a slightly 
elevated transverse fold or by the difference in color 
of the mucous membrane of that region. After this 



CHAPTER XX. 




Patient in knee-chest position, cystoscope about to be inserted (after Kelley.) 



CATHETERIZATION OF URETER. 233 

landmark has been found, the ureteral orifice on 
either side may be discovered by turning the specu- 
lum laterally through an angle of some thirty de- 
grees, and looking sharply. Under normal conditions 
little jets of urine may sometimes be seen coming 
from the orifice, and in some pathological cases pus 
or blood can be detected as it trickles from it into 
the bladder. The appearance of the ureteral orifice 
varies considerably. It may look like a dimple or 
a little pit in the mucous membrane, while at other 
times it resembles an inverted V lying obliquely with 
the apex pointing outward and a little upward. In 
cases in which there has been inflammation it may 
present the appearance of a small round hole in a 
cushioned eminence. In some instances when it is 
difficult to see it at all its situation may be easily 
recognized by watching for the escape of fluid from 
it. The ureteral orifice examined directly in this way 
appears to be nearer the urethra than it really is, 
owing to the illusion produced by the foreshortening 
of the base of the bladder. Dr. Kelly suggests the 
following as a valuable aid to the beginner where 
there is any difliculty in discovering the orifice. " A 
point is marked on the cystoscope at a distance of 
Hve and a half centimetres from the vesical end, and 
from this point two diverging lines are drawn towards 
the handle, with an angle of sixty degrees between 
them. The speculum is introduced up to the point 
of the V, and turned to the right or left until one 
side of the V is in a line with the axis of the body. 



234 ASEPTIC SURGICAL TECHNIQUE. 

Then by elevating the endoscope until it touches the 
floor of the bladder, the ureteral orifice will nearly 
always be within the area covered by the orifice of 
the speculum." 

The searcher (a long delicate sound with the handle 
bent at an angle of 120°) is next employed, and if 
what has been seen is really the orifice, it will at once 
pass readily for a distance of from two to six centi- 
metres into the ureter. The ureteral catheter may 
then be immediately substituted for the searcher and 
the urine can be collected as it passes from the kidney. 

The genu-facial or knee-chest posture possesses ad- 
vantages in most cases, especially where chronic in- 
flammatory thickening of its walls hinders the disten- 
tion of the bladder with air, while the patient occupies 
the ordinary position. In nervous women, or in espe- 
cially difficult cases, the examination should be made 
under anaesthesia; but ordinarily, and especially after 
the surgeon has acquired the necessary skill in the 
manipulations, a general anaesthetic is not needed, a 
little cocaine applied to the urethra five or ten min- 
utes beforehand being usually sufficient to prevent 
pain. 

When it is desired merely to examine the bladder- 
wall, without catheterizing the ureters, the patient 
may be kept in the dorsal position instead of the knee- 
chest posture. The legs are then held back in exag- 
gerated lithotomy position, either by the use of a 
Robb leg-holder or a pair of stirrups, or better by 
two assistants, one standing on each side of the 
patient. 



EXAMINATION OF BLADDER. 235 

The bane of gynaecologists, the so-called " irritable 
bladder," can now be thoroughly studied, and in 
many cases this unsatisfactory diagnosis can be ex- 
changed for one which is descriptive of some definite 
pathological lesion, which with our present methods 
can be satisfactorily treated. In cases of cystitis the 
involvement of the entire wall of the bladder is the 
exception rather than the rule, and very often all the 
symptoms are due to a single patch, or to a small 
number of diseased areas. The exact localization of 
these foci and their treatment by topical applications 
is now a matter of no difficulty, aud under such con- 
ditions it certainly is no longer justifiable to inject 
into the bladder strong caustics which will un- 
doubtedly injure the mucous membrane which has 
remained healthy. 

The application of the method of examination just 
outlined to cases of stone, neoplasm, fistula, tubercu- 
lous ulceration, etc., is so obvious that it need not be 
discussed at length here. 

In other cases an advantage of quite a different 
kind can be gained by the introduction of catheters 
or bougies into the ureter. In certain operations, such, 
for example, as a hysterectomy for carcinoma of the 
cervix and some hysteromyomectomies, it is important 
that the operator should be quite certain of the exact 
location of the ureters. The accident of tying, tear- 
ing, or cutting the ureters has happened to many 
operators, and the making of a uretero-ureteral anas- 
tomosis, the transplantation of the ureter into the 



236 ASEPTIC SURGICAL TECHNIQUE. 

rectum, vagina, or bladder, or even the removal of 
the kidney which was involved, did not always pre- 
vent a fatal result. If bougies be introduced into the 
ureters and pushed up over the brim of the pelvis 
towards the kidney, the ureters may be distinctly felt 
as hard cords and avoided throughout the operation. 

But sometimes it may be desirable to catheterize 
the ureter without the preliminary dilatation of the 
urethra. To do this the patient is placed on the table 
with the buttocks close to the edge and with the legs 
flexed upon the abdomen. The urine from the blad- 
der having been drawn off, the situation of each ure- 
ter as it enters the bladder is made out according 
to the method suggested by Sanger, — by palpation 
through the anterior vaginal wall. A speculum is 
next used to retract the posterior vaginal wall, so that 
the anterior wall of the vagina as far as the cervix 
may be watched while a sterile solution of methylene 
blue is injected into the bladder. When the bladder 
has been sufficiently distended (150-200 c.c. of the 
solution are usually sufficient for this purpose), the 
catheter with metal plug inserted in its outer end is in- 
troduced into the bladder and a search is made for the 
ureteral orifice. One has to be guided in this search 
chiefly by the sense of touch, although some aid can 
be obtained from watching the situation of the point 
of the instrument as far as it is possible to do so 
through the anterior vaginal wall. When the point 
of the catheter comes in contact with the ureteral 
eminence, it may be felt to give a distinct " trip," and 



CATHETERIZATION OF MALE URETER. 237 

the sensation of a slight jar will be conveyed to the 
thumb and finger in which it is held. After one or 
two attempts the tip of the catheter becomes engaged 
in the orifice of the ureter, after which it will not be 
difficult to pass it well up. The plug is then removed 
from the outer end and the urine is collected. If it is 
unmixed with methylene-blue solution there can, of 
course, be no doubt that the catheter is in the ureter. 
A second catheter may, if desired, be passed into the 
ureter on the opposite side. There is, perhaps, no 
more satisfactory clinical test than to see pus trickling 
from one ureteral catheter while clear urine is at the 
same time running from the other. This method of 
working " in the dark" is, of course, much less satis- 
factory, and requires more skill and training than the 
one first described, and indeed the easier method will 
meet the requirements of nearly every case. 

Catheterization of the ureters in the male is a far 
more difficult procedure, and in those cases which do 
not permit of a satisfactory cystoscopic examination 
on account of marked intravesical enlargement of the 
prostate may be regarded as impossible. In 1894 the 
late Dr. James Brown, of Baltimore, was successful 
in several cases. He employed a modification of the 
Nitze-Leiter cystoscope suggested by Dr. Brenner, 
who, however, was not able to catheterize the male 
ureter. The results of this method have proved highly 
satisfactory, and as a result of improvements in our 
technique the procedure has now come into more gen- 
eral use, especially in the hands of Dr. Hugh Young. 



CHAPTER XVIII. 

PATHOLOGICAL EXAMINATIONS. 

A knowledge of pathology acquired from the study 
of text-books alone will be found of comparatively 
little use in practice. Histology, pathology, and bac- 
teriology can be learned only in the laboratory, and a 
surgeon who has studied under the microscope only 
those specimens which have been prepared for him by 
others, and who has not actually handled the fresh 
tissues and practised the methods of preparing them 
for microscopic examination will find himself wofully 
deficient when he is thrown upon his own resources. 
It is true that a busy surgeon may sometimes be com- 
pelled to delegate the mechanical part of the work to 
an assistant or to a colleague who devotes his time 
especially to pathology, but unless he has himself 
served an apprenticeship in this kind of work, he will 
be unable properly to appreciate what is done for him 
or make the best use of the results in the management 
of his cases. 

In the best surgical clinics it is now a part of the 
regular routine to make microscopical examinations in 
some of the more difficult cases, before, during, and 
after the operation. Such examinations may be made 
primarily for clinical purposes and as an aid to diag- 
nosis or prognosis in some particular case. But look- 
238 



PATHOLOGICAL EXAMINATIONS. 239 

ing at the subject from another stand-point it will 
readily be seen that any one who has learned how 
to utilize the material which comes from surgical 
operating-rooms will find that it serves admirably 
for purposes of research, inasmuch as the tissues 
may be placed immediately after removal from the 
living body into fixing reagents, thus yielding prepa- 
rations far more desirable for study than can ever 
be obtained at autopsies. Any surgeon who will 
systematically examine by the various known methods 
specimens from all parts removed at his operations 
and make careful notes of what he finds in them, 
will soon have accumulated a mass of information, 
a study of which cannot fail to be of use to him in 
directing and controlling his subsequent work. The 
waste of the amount of interesting material which is 
thrown away from the larger operating-rooms in the 
course of a year is indeed to be deprecated when one 
thinks of the advances in our knowledge which might 
result if even a small proportion of it were carefully 
worked up. 

Examinations of Tissues for Diagnosis. — Even in the 
practice of the best-trained men there will often occur 
cases in which some doubt exists as to the exact nature 
of a lesion, and in which it is often desirable, in order 
to decide upon the nature of the operation required, to 
determine definitely the character of the pathological 
changes which have taken place. The examination 
of a small portion of tissue cut out for this purpose or 
of the parts removed at a preliminary operation will 



240 ASEPTIC SURGICAL TECHNIQUE. 

often throw much light upon the subject. In such 
cases the surgeon will be guided not alone by the 
macroscopic appearance of the tissue, but also by the 
study under the microscope of sections of the fresh 
unhardened tissue and of stained preparations made 
after the specimen has been fixed and hardened. Too 
much attention cannot be paid to the gross appearances 
of the tissues. The trained eye is sometimes able from 
these alone, not only to decide with some degree of 
certainty what is the probable nature of a given tumor, 
whether, for example, it is cancerous or not, but also 
to prophesy more or less accurately as to the particular 
type of growth present in the specimen under consid- 
eration. The color, the consistence, the translucency, 
the appearance on section, the juiciness, the vascular- 
ity, the presence or absence of areas of necrosis or of 
fatty degeneration will all be aids to diagnosis. It is 
not often, however, that the naked-eye examination is 
positively conclusive, and where there is any doubt at 
all we should not rely on this alone, since the study of 
fresh sections will in the vast majority of cases, to a 
good observer, decide the diagnosis definitely, and the 
ease and quickness with which such microscopic ex- 
aminations can be made on the spot make it worth 
while to have the means of carrying them out in a 
room adjoining the operating-room, so that during an 
operation a bit of tissue can be examined immediately, 
and the further course of the operation be determined 
by the results obtained. The fresh sections may be 
made with a double knife (Valentine's knife) or by 



PREPARATION OF SPECIMENS. 241 

means of an ether or carbon dioxide freezing micro- 
tome, which is suitable for general work. These 
sections may be examined immediately in physiologi- 
cal salt solution, or they may be first stained (without 
previous hardening) in Carnoy's solution or with 
methylene blue dissolved in salt solution. Of course a 
certain amount of practice is necessary in order to 
make use of this method of examination, but the time 
spent in acquiring the requisite skill is by no means 
wasted. It is often possible in this way to diagnose 
cancerous or tuberculous tissue within five minutes 
after its removal from the body. Where there is no 
necessity for haste, the tissues may be dropped into 
fixing solutions and taken to the laboratory for thorough 
examination. But even in these cases portions of the 
specimen should always be examined fresh in salt 
solution, since certain changes (e.g., fatty degeneration) 
can be made out most satisfactorily by this method. 
For fixing and hardening specimens strong alcohol or 
a ten-per-cent. solution of formal will be found satis- 
factory for ordinary work. The pieces placed in the 
hardening fluid should be as small as they can be 
conveniently made without injuring the specimen, 
since it may sometimes happen that when they are 
of too great a size the central portions may not be 
reached at all by the hardening agent. After being 
hardened the tissues are transferred to absolute alcohol 
for twenty-four hours, and are subsequently passed in 
the ordinary way through a mixture of absolute alco- 
hol and ether into thin celloidin, where they remain 

16 



242 ASEPTIC SURGICAL TECHNIQUE. 

for from twelve to twenty-four hours. They are then 
transferred to thick celloidin for the same time, and 
after being embedded (in celloidin) on cork or on 
pieces of wood, and being allowed to remain for a few 
hours in eighty-per-cent. alcohol, they are ready to 
be cut into sections. Each microscopist has his prefer- 
ences for staining dyes, but hematoxylin or methy- 
lene-blue, and eosin, or alum-cochineal will be found 
satisfactory for routine work. For a more minute 
study than that usually required for ordinary diagnosis 
(e.g., the study of karyokinesis in neoplasms) very 
small pieces may be fixed in a seven-per-cent. solution 
of sublimate in salt solution for half an hour, and 
afterwards hardened in graded alcohols. Still more 
satisfactory results may be obtained by the use of 
Flemming's solution or Hermann's fluid. If sections 
be cut from small pieces of tumors which have been 
fixed in these fluids, subsequently hardened in alcohol, 
and embedded in paraffin, and these sections be stained 
on the slide (being fixed by means of Mayer's albumen) 
with safranin, or gentian violet, they will show ex- 
quisite mitoses (nuclear figures). In fact these are the 
measures now used by histologists for research work 
in this direction. It has been thought advisable to 
give here a few of the methods which are most com- 
monly employed, and which have been found reliable ; 
detailed directions on this subject will be found in the 
text-books on histological technique. 

When a search is to be made for bacteria in the 
tissues, they should be hardened in absolute alcohol, 



PLATE XXI. 



*v'".*» »-".V.'.- '•"'•• '. :'.'\ Vv; 'v.: '.•:.•:'■;'■ : pW '• '. '. ' ; .'-'. •VAgrfiV-' 

. 5. i '•• • •■ -' '• . • .* *• - •• *'••••...'• "s« . . . . v . •■ V r! 
• . '?£■:$ -.:•.-•■■■•■•■. ■'. '-•% *.:• ;•"-. • • •.•-■ • • • . ■ .. • i ;• 

V : *'. : ••.:••.•.*•::•■.•• '-f* V-*V ^•■••^ : --.' : -.-- :•'•./ -^!- 

• • N - **v • . - ". ■ • • '• , .*. . •'''. i ' . . *v«*. ; .* •■ • .*.;'* 
\*V VV • '. :" '■ • .- ' • - • . • '•'<?> V.» ' • *•'•-• • •:"•".' •' .'•*'* 



: • • . ■ • ' .1""'. - • 



••■ ^ v^' ; >"v- -*0: '•:>. .vv-. •:;.•::•;.•• ■-..:*/ 
y *. .*•".*. " v : -* ' • . ■ •• ••.'/ /•:*. • : ' • ' ' • * • 

Fig. 1.— Normal raucous membrane of the uterus. (After ZweifeL) 



^5 



:^/->S ; '!'i 




' ^;n ' ■S^S'^SSM 






Fig. 2.— Chronic interstitial endometritis. /After Zweifel.) 



PREPARATION OF SPECIMENS. 243 

embedded in celloidin, stained with Weigert's fibrin 
stain or with Loffler's or Kuhne's methylene blue, and 
studied with an immersion lens. 

The Examination of Scrapings from the Uterus. — Many 
contradictory opinions exist as to the value of the con- 
clusions regarding pathological conditions within the 
uterus which can be deduced from a microscopic study 
of scrapings from this organ. While some authorities 
have laid too much stress upon the reliability of the 
results to be obtained in this way, others consider them 
to be totally without value. As usual, the truth seems 
to lie between the two extremes, and the best observers 
seem now to be agreed that, when taken in conjunction 
with thorough physical examinations and a careful 
analysis of the symptoms of which the patient com- 
plains, a microscopic study of the tissues obtained from 
the uterus will often aid us in arriving at a definite 
diagnosis. It is often extremely important to examine 
a few millimetres of the uterine muscle which lies 
immediately beneath the mucous membrane of the 
affected part, and, since in the operation of curetting 
one does not usually go to a sufficient depth for this 
purpose, it is often advisable to cut out a piece from 
the diseased region with a knife in order to make sure 
of securing a portion of the tissue which we desire to 
examine. 

If portions of the uterine mucous membrane be em- 
bedded in celloidin the sections must not be passed 
through fluids, such as alcohol or oil of cloves, which 
will remove the celloidin ; otherwise on account of its 



244 ASEPTIC SURGICAL TECHNIQUE. 

delicacy some of the tissue will be carried away with 
it. Some prefer to stain the pieces in bulk, and to 
embed in paraffin. If this is done and if the sections 
are securely fastened to the slide by means of Schalli- 
baum's collodion, Mayer's albumen, or Gulland's water 
method, before the paraffin is removed, we may feel per- 
fectly sure that no part of the tissue, not even a single 
cell, will be lost or displaced. But for ordinary work 
the celloidin method will be found most convenient, and 
if ninety-five per cent, alcohol be used for dehydrating 
them, and oil of bergamot or creosote for clearing them, 
there will be no danger of mutilating the sections. 

To appreciate the pathological changes which have 
taken place, it is of course necessary to have examined 
a large number of specimens made from the normal 
uterine mucosa. But in order to keep in mind the 
finer changes it is also desirable to have always at hand 
for comparison a number of sections of normal tissue 
taken from different cases. "With this method of con- 
trol one can more safely judge of an increase in the 
number of the glands, of variations in their size, shape, 
or arrangement, and of alterations in the interglandular 
stroma. (Plate XXL, Figs. 1 and 2.) After a little 
practice it will be possible to recognize the different 
forms of endometritis, from the acute septic variety, 
with necrosis of the mucous membrane due to infec- 
tion with pyogenic bacteria, to the most chronic forms, 
characterized by atrophy of the mucosa and new growth 
of connective tissue, or any of the intermediate varie- 
ties, whether they are acute, subacute, or chronic. In 



EXAMINATION OF SPECIMENS. 245 

many cases no striking alterations in the mucosa are 
found. One of the most important facts which these 
microscopic examinations, when employed in conjunc- 
tion with palpation and visual examination of the in- 
terior of the uterus, have taught us, is, that definitely 
localized lesions of the mucous membrane of the 
uterus can exist, and that in many of the so-called 
cases of endometritis the whole mucous membrane is 
not uniformly affected, but the disease is limited to 
certain well-defined areas, and often indeed is sec- 
ondary to other conditions, such, for example, as a 
small polpyus, or to a myoma in the wall of the uteius. 

The finding of chorionic villi in scrapings made after 
a hemorrhage from the uterus has taken place, with no 
apparent reason to account for it, will sometimes give 
a clue to the cause of the bleeding, which has, perhaps, 
been unsuspected not only by the physician, but also 
by the patient. The appearance of the villi when seen 
is sufficiently characteristic, but, as in some cases they 
are not numerous, careful search should be made 
through different sections, when an abortion is sus- 
pected, before deciding that they are not present. 
(Fig. 42.) 

The surgeon is, however, most frequently called upon 
to decide from his examination of pieces removed from 
the uterus whether or not malignant disease of the 
organ exists. Cases not infrequently occur in which 
the first section will reveal the presence of an un- 
doubted carcinoma or sarcoma at a time when the 
clinical phenomena are insufficient to determine the 



246 ASEPTIC SURGICAL TECHNIQUE. 

diagnosis, and at other times even when they are such 
as apparently to justify the conclusion that the dis- 

Fig. 42. 




Section through a blood-elot from the uterus after abortion, showing transverse 
and longitudinal sections of chorionic villi. (After Orth.) 

ease is benign. Often, however, in cases in which the 
clinical indications are doubtful, the results of a micro- 
scopical examination are also not positive, and in such 
cases the course of procedure should be determined 
upon only after all the phenomena concerned, both 
clinical and pathological, have received due consider- 
ation. 

Many unfortunate errors in diagnosis have resulted 
from the tendency of pathologists to rely too much on 
isolated signs in the sections and to base a diagnosis 



EXAMINATION OF SPECIMENS. 



247 



of malignant disease on a single abnormality, such, for 
instance, as atypical gland-tubes, variations in the size 
of the epithelial cells in the same tubule, the occur- 
rence of solid columns of epithelial cells, the irregular 



Fig. 43. 




Adenocarcinoma of the uterine body. (After Orth.) 

branching of the glands, and certain alterations in the 
6troma. It has been shown that any one or several of 
these conditions may occur in endometritis or asso- 
ciated with benign neoplasms, such as a simple poly- 
pus or a myoma. Again, the occurrence of gland 
tubules within the muscle is not pathognomonic of 
malignancy, for they have not rarely been found to 
penetrate thus far in myomatous disease or even under 
normal conditions. It may be accepted as a fairly safe 
rule for guidance that, except in those cases in which 



248 



ASEPTIC SURGICAL TECHNIQUE. 



definite cancer nests can be seen in the stroma be- 
tween the glands, it is not justifiable to diagnose posi- 
tively carcinoma of the uterus from these microscopic 
sections alone, unless the new growth can be seen in- 
vading the muscle and causing it to disappear before it. 
(Fig. 43.) But while a positive diagnosis can rarely be 

Fig. 44. 




Epithelioma of the cervix. (After Orth.) 

made, the existence of many suspicious changes in the 
mucous membrane will often warrant the conclusions 
on the part of the pathologist which when controlled by 
the study of the symptoms which the patient presents 
will enable the operator to decide what to do. On the 



EXAMINATION OF SPECIMENS. 249 

other hand, in cases which from a clinical stand-point 
strongly suggest malignancy, but in which the tissues 
obtained by curetting yield no suspicious pieces what- 
ever, needless operations may oftentimes be prevented. 
Sections from the cervix are often particularly puz- 
zling, and all the different possibilities — erosions, con- 
genital anomalies, benign hyperplastic growths, vari- 
ous forms of inflammation, as well as neoplasms — have 
constantly to be borne in mind. (Fig. 44.) Cullen's 
work, entitled " Cancer of the Uterus," deals admirably 
with the whole question, and will be found invaluable 
as a book of reference for the working gynecologist. 

Examination of Cyst Contents. — On account of the 
danger which accompanies it, exploratory puncture 
of abdominal cysts is now seldom resorted to for 
purposes of diagnosis, and since an abdominal sec- 
tion even for exploration has been rendered a safe 
procedure, it is not now necessary to depend so much 
upon the examination of the fluid from cysts to aid us 
in diagnosis. But, apart from the fact that the exact 
character of the contents of cysts of different origins 
must always be of interest, there are still occasions 
when useful, practical data for diagnosis and prog- 
nosis can be obtained from these examinations. In 
not a few abdominal cysts even an exploratory lapa- 
rotomy will not always clear up our doubts as to the 
origin of the tumor where it is densely adherent to 
neighboring structures ; and cysts of the bile-ducts, 
pancreatic cysts, and the like often go unrecognized or 
are misnamed when a careful physical, chemical, and 



250 ASEPTIC SURGICAL TECHNIQUE. 

microscopical examination of their contents might suf- 
fice to correct the mistake. The examination should 
be carried out by means of the ordinary methods ; the 
color, odor, reaction, and specific gravity should be 
carefully noted, and the quantity of albumin, sugar, 
and biliary bodies, if any of these be present, should be 
accurately ascertained. Less stress is now laid upon 
the significance of the presence of paralbumin and 
metalbumin or pseudomucin (Hammarsten, Scherer) 
since the irregularity and inconstancy of their occur- 
rence in ovarian cysts and their occasional appearance 
in other fluids have been pointed out. The tests for 
these substances, however, are not difficult to carry 
out, and the results obtained when considered together 
with the other characters of the fluid may be of help 
for a differential diagnosis. The striking power of 
coagulation possessed by the fluid from fibro-cystic 
tumors of the uterus is familiar to all. 

The microscopic examination of the sediment ob- 
tained by centrifugalization or by permitting the fluid 
to stand for a few hours in a conical glass may be posi- 
tive. The various forms of cells — blood-corpuscles, 
pus-cells, or epithelial cells — present should be noted. 
The " budding cells" to be seen in the fluid which 
has been in contact with a cancerous peritoneum 
are quite characteristic and of some diagnostic value, 
although by no means pathognomonic. The presence 
of crystals of cholesterin, of echinococcus hooklets, 
or of renal elements may help to clear up the case. 
The walls and the contents of dermoid cysts can 



A UTOPSIES. 251 

usually be recognized by the naked- eye examination 
alone. 

Autopsies. — Besides the careful routine examination 
of all organs and parts of organs removed at oper- 
ations, the surgeon should try to obtain autopsies, where 
it is at all possible, on the cases which die while under 
his care. The importance of such examinations for an 
appreciation of the frequency of infection after oper- 
ations has already been insisted upon, and any one who 
performs many operations and yet states that he " has 
had no opportunities of studying infection since the 
introduction of an aseptic or antiseptic technique," is 
either deceiving others or himself. 

The autopsy in a case of infection is not by any means 
completed when the cause of death has been deter- 
mined. Each case should be carefully studied for 
itself ; the causal micro-organisms should be separated 
and identified ; the portal by which the infectious agent 
entered the system should, if possible, be determined ; 
its course and the mode of its extension to other parts 
should be followed, and any part played by concomitant 
diseases of heart, liver, kidneys, etc., in predisposing 
to infection, should be considered. In cases in which 
death has occurred without any apparent infection, the 
surgeon or pathologist should satisfy himself by bac- 
teriological methods that there really has been no 
bacterial invasion. Partial and incomplete autopsies 
are, of course, better than none ; but a little tact will 
usually gain the necessary permission for a complete 
autopsy, which should be made as soon as possible after 



252 ASEPTIC SURGICAL TECHNIQUE. 

death and before putrefactive changes have taken place, 
so that all the organs may be carefully worked up. 
Only in this way can a knowledge of the correlation of 
diseases and of the interdependence of pathological 
changes within the pelvis and those elsewhere in the 
body be satisfactorily obtained. Only when the gross 
appearances of all organs have been carefully studied 
and described, when the tissues have been examined 
microscopically both in a fresh state and after being 
hardened and stained, and a complete bacteriological 
examination has been made, can we feel that we are in 
a position to pronounce judgment upon the case. The 
difficulties in the way of a thorough understanding of 
some cases which have been thus thoroughly studied, 
are sometimes great, and this very fact should make us 
all the more unwilling to be satisfied with the crude 
opinions founded upon imperfect and incomplete au- 
topsy work. 



CHAPTER XIX. 

ENDOMETRITIS | NOMENCLATURE — HISTOLOGY — CHANGES IN 

ENDOMETRIUM DURING MENSTRUATION AND IN OLD AGE 

THE DECIDUA — INFECTIONS — GONORRHOEA — SEPTIC ENDOME- 
TRITIS TROPHIC ENDOMETRITIS. 

So far as nomenclature is concerned, the discussion 
of diseases of the lining membrane of the uterus has 
given rise to a great diversity of opinion. Influenced 
by the unsatisfactory nature of most of the work on 
these lines done by his predecessors, almost every 
author has felt free to introduce his own classification. 
Nevertheless, in spite of all that has been written upon 
the subject, we possess to-day no really satisfactory 
division of these lesions of the endometrium. 

Perhaps the chief cause for this unsettled state of 
affairs is to be looked for in the anatomy of the mem- 
brane, which is quite unlike the simpler mucous sur- 
faces of other parts of the body. A second cause of 
great confusion arises from the wonderful range of 
alterations through which normal endometrium passes 
in its perfectly physiological changes. 

A few words about the histology of the endometrium 
may not be out of place. The uterine wall is divided 
into three layers of tissue : From without inward we 
find first the serous peritoneum, which, however, does 
not completely cover the uterus, being reflected over 
the bladder, the rectum and the broad and round liga- 
ments. Beneath the peritoneum lies the portion 

253 



254 ASEPTIC SURGICAL TECHNIQUE. 

which constitutes the main thickness of the uterine 
wall — the myometrium. The innermost layer that 
lines the cavity is the endometrium. This consists of 
a soft, red, somewhat velvety tissue, normally smooth 
and glistening. It is divided into two distinct portions, 
the one lining the cavity below the internal os, the 
other lining the fundus. These differ markedly from 
one another. The cervical portion is somewhat corru- 
gated, being thrown into folds, forming what is known 
as the arbor vitce uterina. Over this area a certain 
amount of tenacious material is often found, inasmuch 
as the cervical glands secrete mucus and in this way 
differ from those at the fundus. 

The mouths of these glands may at times be recog- 
nized as tiny pin-point holes ; and often small retention 
cysts, full of mucus, gleam through the tissue — the 
Nabothian follicles. The glands are branching race- 
mose in type, and run down to, but not into, the muscle 
layers. The epithelial lining cells are very high, colum- 
nar in type, and show a dark-staining nucleus far 
down at the extreme base of each. The cells are taller, 
and the nuclei placed lower than in the gland cells 
nearer the fundus. The interglandular stroma here is 
not so rich in cells as that of the endometrium near 
the fundus ; and those seen are small, and of the con- 
nective type. (Plate XXII, Fig. 1.) 

Above the internal os, the uterine lining is of the 
other type. Here the membrane is thicker, ranging 
from 0.5 to 3 mm. in thickness, according to the physio- 
logical stage. There is no basement membrane, the 
stroma ending sharply at the muscle edge. The glands 



PLATE XXII. 










r/J 



& 







Fig. 1.— A normal cervi- 
cal gland. (After Cullen.) 

A, squamous epithelium, 
vaginal type, not horny; 

B, typical cervical gland ; 

a, cylindrical epithelium; 

b, c, secondary glands, and 
tufts of epithelium ; d, 
illusion of many-layered 
epithelium, due to oblique 
cutting of section ; e, cap- 
illary. 



'tfJA(-%m 



/ .4 



Fig. 2. — Normal senile 
endometrium. (After Cul 
len.) a, flattened epithe- 
lium ; b, commencement 
of muscle tissue. 



IK 

V: ; 



m 



'd w> 



<f 










'i 




$ 


f% 


tk 


' 


$ 


'.V 


m 


■IS 


si5> 




ft . 


9 


-o 


fc j 








b 



ENDOMETRITIS. 255 

are of the simple branching type, quite equally spaced, 
and appearing in section as small round openings. 
These glands, unlike those near the cervix, occasionally 
invade the myometrium. Such small down-growths, 
as has been pointed out, serve an important purpose, 
as it is from such protected bits of epithelium that the 
whole endometrium is regenerated after the operation 
of curettage. The epithelial cells of these glands are 
also columnar, but lower than those of the cervix. The 
epithelial nuclei of this portion of the endometrium 
are more vesicular, and lie further away from the base- 
ment membrane than those of the cervical cells. The 
epithelial cells are ciliated, the current passing down- 
ward. The interglandular stroma of the endometrium 
above the internal os is characteristic, and sharply dis- 
tinguishes this tissue from all the other lining mem- 
branes of the body. At first glance, the microscopic 
picture seems to be one of lymphoid tissue. This, 
however, is not the case. The tissue is very rich in 
rather large oval cells, each almost completely filled 
with a dark but vesicular nucleus. On careful exami- 
nation, a network of fibrils may be seen, uniting con- 
tiguous cells, and there is also a very loose connective- 
tissue frame-work supporting the cells. There are 
numerous blood-spaces, and many large lymphatics. 
Occasional true leucocytes are seen, to be recognized 
by their small, black, round nuclei. As has been said, 
the stroma closely resembles embryonic connective 
tissue. The lymph-spaces are quite noteworthy, be- 
cause of the part they play in the spreading of infec- 
tions of the uterine cavity. The large open spaces 



256 ASEPTIC SURGICAL TECHNIQUE. 

throughout the stroma of the endometrium pass 
through and are collected in trunks which penetrate 
the myometrium. Under the peritoneum, they again 
unite into larger spaces, which pass out along the broad 
ligaments to the large external iliac and sacral glands. 

Let us now look for a moment at the principal phys- 
iological changes which occur in the endometrium, at 
times producing pictures so unlike the normal, as just 
described, as to lead one to believe he is dealing with 
a pathological lesion. 

The cycle of menstruation, completed during the 
sexual life of a woman about every twenty-eight days, 
causes such constant mutations that the membrane is 
quiescent only about twelve days in a month. There 
are five days of swelling, four days of desquamation 
and actual menstruation, and five days of regeneration. 
When one makes a microscopical examination of the 
endometrium at the height of menstruation, marked 
changes are noted. The vessels are greatly distended, 
many are ruptured, and blood, outside the vessels, is 
seen throughout the section. The entire endometrium 
is thickened. There is marked hypertrophy and pos- 
sibly dilatation of the gland-spaces. Much of the glan- 
dular epithelium is found swollen and desquamated, 
the lumina of the glands being partly filled with blood 
and epithelial debris. There is also a marked increase 
in the number and size of the typical stroma cells, 
the so-called " lymphoid elements," which, as we have 
seen, are not of lymphatic origin at all. 

In marked contrast to the picture found during 
menstruation is that present in old age. Here the 



ENDOMETRITIS. 257 

membrane is extremely thin, the epithelium sometimes 
resting almost directly upon the myometrium. The 
interglandular stroma is very scanty, the normal large 
cells being few and replaced by connective tissue. The 
glands are scanty, small, and simple. (Plate XXII. , 
Fig. 2.) 

One other physiological product of changes in the 
endometrium must be mentioned — the decidua; for so 
often is one mislead by the unexpected finding of decid- 
ual remains in curettings, that the picture of this con- 
dition must always be borne in mind. In decidual 
formation we find a marked thickening of the endo- 
metrium. In sections, two layers can be made out; a 
compact layer of large decidual cells lying nearer the 
lumen, and another much thicker layer, lining the 
myometrium. This latter is quite spongy, being made 
up of large spaces that represent the greatly hyper- 
trophied uterine glands. These glands become very 
large, tortuous, cork-screw-like, and complex. They 
lie close together, with but little stroma between them. 
The cells of the glands are much more cuboidal than 
in normal epithelium. The stroma cells of the com- 
pact inner layer are very large, with large vesicular 
nuclei that do not fill the cells entirely. The cells are 
oval and are of connective-tissue origin. They simply 
represent the normal stroma cells of the endometrium 
greatly enlarged by the influence of the pregnancy. 
Of course, we may find traces of villi also ; but as they 
are of fetal origin, they do not come into our consider- 
ation of endometrium, although, if present, they clinch 
our diagnosis of decidua. 



258 ASEPTIC SURGICAL TECHNIQUE. 

Let us now turn to pathological conditions, endome- 
tritis. This very word is often a misnomer, as the ter- 
mination itis in pathology is used to indicate inflamma- 
tion. But while many of the diseases we are accus- 
tomed to group under the title " endometritis" are true 
inflammations, due to infections by micro-organisms 
which may be demonstrated, other affections of the 
lining membrane of the uterus appear to be due to 
causes other than infections, or at least the conditions 
are too obscure to permit the demonstration of such 
an infection. Although, then, it seems wise to retain 
" endometritis " because of its venerable age, the term 
must be understood to cover more than the true infec- 
tions of the endometrium. 

For lackof a better term, let us designate as " trophic " 
all those forms of endometritis which are apparently 
not attributable to bacterial infection, but which seem 
to originate from disturbances in the nutrition of the 
lining membrane. Such conditions may be due to 
abnormal positions, new growths, or to other abnormal- 
ities in the uterus or adnexa. Our other chief heading 
will then be " infections "; and these two divisions 
include all diseases of the endometrium except the 
neoplasms. 

Infections of the Endometrium. — Of the infectious 
groups, two subdivisions can be made ; (a) acute, (6) 
chronic. The most common form is due to the gono- 
coccus. It would be hard to estimate how many 
women are thus infected ; but the numbers given for 
the United States— 800,000-1,000,000— may be taken 
as an index of the morbidity. Somewhere about 30 



ENDOMETRITIS, 259 

per-cent. of all infected with the gonococcus are ren- 
dered sterile, which means that the endometrium, or 
the endometrium and tubes together, are involved. 

Such patients usually give a history of some slight 
burning or frequent micturition, accompanied by a 
slight yellowish discharge, which may have been 
present some time. Then rather suddenly, and usually 
following a labor, or at the time of a menstrual period, 
the acute attack comes on. There may be a slight 
chill, with some fever, pain, and a burning sensation in 
the lower abdomen, the pain being fairly constant, not 
cramp-like. There is usually a thicl#, yellowish vaginal 
discharge showing considerable mucus. In a simple 
case, the condition is never so severe as in forms of 
endometritis due to such organisms as streptococcus. 
The attack lasts from 7 to 10 days and gradually sub- 
sides, often passing over into the chronic form. Very 
frequently the infection travels by direct continuity out 
into the tubes, setting up a salpingitis which markedly 
alters the prognosis. This process is not disseminated 
by way of the lymphatics, as in cases of streptococcic 
infections. 

The bimanual examination shows little except the 
leucorrhcea and an enlarged, sensitive uterus. Of 
course, a salpingitis can be made out when marked 
sensitiveness or masses are felt on the sides. There is 
usually a slight leucocytosis — from 10,000 to 14,000. 

Treatment for this condition calls chiefly for rest in 
bed, as the disease is self-limiting ; a light " soft " diet 
should be given. Hot applications, such as a flaxseed 
poultice, fresh every three hours, kept hot by a hot- 



260 ASEPTIC SURGICAL TECHNIQUE. 

water bottle, should be used if there is much abdomi- 
nal pain. Hot douches should be given two or three 
times daily, depending upon the amount of the dis- 
charge. One of these may consist of a quart of 1-1,000 
permanganate of potassium solution. For other 
douches a J of 1 per-cent. solution of phenol may be 
employed ; or the so-called Pulv. Menth. Comp. 

R 01. Menth. Pip 1.5 

Ac. Carbolic 3 

Pulv. Alum 8 

Ac. Boric 32. 

Sig. — fwo teaspoonfuls to one pint of water. 

Any marked urethritis or cystitis must be treated. 
Urotropin may be given to protect the bladder, and 
argyrol (20 per-cent.) or silver nitrate (2 per-cent.) may 
be applied to the inflamed urethra, a toothpick wrapped 
with absorbent cotton being convenient for this purpose. 
Such applications are made about every other day. 
Bladder irrigations of a quart of a saturated solution of 
boric acid and normal saline solution (equal parts) may 
be used daily if the cystitis is severe. When the acute 
condition and fever have subsided, the uterus should 
be thoroughly curetted, and then irrigated. As to the 
use of antiseptics and powerful caustics in the uterine 
cavity, they are much better omitted. They cannot 
reach deep into the tissue, anyhow, and their only effect 
is to cause a local necrosis, and later a slough which 
subsequently provides in itself an ideal culture medium 
for micro-organisms. 

The tissue removed by curetting in such cases is 
abundant. On section, the picture is typical of acute 



PLATE XXIII. 



f* Jt* ** * 



//jv- i; - */»■ *-v & #%- • • ■• • •**'■ 



Fig. 1. — Interstitial exudative endometritis. (After Winter and Ruge.) 




Fig. 2. — Hypertrophy of uterine glands. (After Cullen.) a, a, section of 
normal glands ; b, normal glands distorted by curette ; c, c, c, all portions of one 
gland, cut across its folds; d, d, like "c," except that the continuity can be 
traced ; e, hypertrophied, but less convoluted than " c" and "d." 



ENDOMETRITIS. 261 

inflammation. The epithelial cells of the glands are 
much swollen, and frequently their nuclei stain poorly. 
Many are desquamated, and the gland lumen is filled 
with cast-off cells and leucocytes. The stroma cells are 
also swollen, and separated by an exudate, in which 
great numbers of leucocytes, chiefly polymorphonu- 
clear, are seen. At times, typical gonococci may be 
stained within these leucocytes. The blood- and lymph- 
spaces are dilated, and some local hemorrhagic areas 
may appear. When the curetting has been done, as it 
should be, at the end of the acute attack, the picture 
may present features less definite than those just 
described. (Plate XXIIL, Fig. 1.) 

Septic Endometritis. — The second, and most serious, 
of the forms of acute infectious endometritis may be 
termed septic, though the term really includes the 
gonococcal form also. The organisms concerned may 
be any one, or a mixture, of a large number — B, coli, 
Streptococcus, Staphylococcus, B. diphtherial, B. pyocy- 
aneus, and others. Streptococcus is very common — 
probably the most common — and is the most to be 
dreaded. Such cases occur almost exclusively after a 
labor or after an operation in the uterine cavity, for 
example, a curetting. When, by means of a dirty 
instrument, dirty fingers, or dirty dressings, infectious 
material containing some of the above-mentioned 
micro-organisms has been introduced into the uterine 
cavity, deprived of its normal protective lining, we may 
expect an ordinary wound infection to occur. One 
cannot be too deeply impressed with the magnitude of 
the risk. Even if hands, instruments, and dressings 



262 ASEPTIC SURGICAL TECHNIQUE. 

have been sterilized by a perfect technique, the danger 
remains, although greatly lessened. The field in which 
we have to work is one of the dirtiest and one of the 
most difficult to clean of any in the body, and to get 
it really sterile is probably impossible. One need only 
look at a stained smear from the lower vagina or the 
perineal skin to be convinced of this fact ; even after 
the most careful cleaning up, bacterial forms still 
abound. All we can hope to do is to remove the 
pathogenic forms as far as possible, or at least to reduce 
their numbers to such an extent that the protective 
agencies of the body can successfully contend with 
such as remain. To accomplish even this result 
requires the most careful conscientious application of 
all the rules for asepsis that have been laid down in 
the preceding chapters. And in spite of all precau- 
tions, the most careful man will still have his occasional 
case of puerperal fever; but be it remembered that the 
more careful he is, the more " occasional " will such 
cases be. 

Puerperal Fever. — It is not in our province here to 
speak at length about this condition — a disease that 
involves far more than the endometrium. But as the 
infection is first planted in the uterine lining, we must 
consider the matter to some extent. 

The symptoms differ slightly, as modified by the 
condition, whether it be post-operative or post-partum. 
Let us take a typical case of the latter form. The 
mother does well for 24 or 48 hours after the labor. 
The bloody lochia appears about normal in amount, 
and has no special odor. Frequently, in the afternoon 



ENDOMETRITIS. 263 

of the second day after labor (after from 48 to 54 
hours) there will be a chill, which comes on quite sud- 
denly, and may be severe, the severity being in direct 
proportion to the virulence of the infection. The tem- 
perature after the chill rises to 102° or more, often 
going as high as 105°. The pulse is quickened, but 
usually remains under 120, inasmuch as the puerperal 
bradycardia persists to some extent, and one does not 
get as rapid a rate as one might expect from the tem- 
perature. If the case is post-operative, the pulse may 
be more rapid. There is generally little or no pain — 
possibly some tenderness low in the middle, or some 
degree of colic. It is usually about this time, by 
coincidence and without any causal relation, that the 
breasts are filling with milk, and may be somewhat 
sensitive. The lochia may become abundant, dark 
brown, and more or less foul-smelling if the organism 
be such as B. coli, or some of the lower putrefactive 
forms. It must be borne in mind, however, that in the 
most severe streptococcic infections the trouble spreads 
so rapidly by way of the lymphatics, with so little local 
necrosis of the endometrium, that the lochia remains 
absolutely normal in appearance, though cultures show 
the material to be swarming with chains of cocci. 

On physical examination of the pelvic organs nothing 
pathological can be made out. The uterus is usually 
larger than normal for the length of time since labor, 
and the fundus may reach to the umbilicus, or even 
above it. It is soft, possibly boggy in feel, slightly 
sensitive, and hot. If made out at all, the lateral 
structures appear normal. 



264 ASEPTIC SURGICAL TECHNIQUE. 

In such cases a culture should be taken from the 
cervix. It is a point worth remembering, however, 
that even before taking the culture, we should open the 
bowels thoroughly, best with castor oil. It is surpris- 
ing how many rises of temperature in the puerperium 
never recur after the bowels have been well opened. 
If the uterus is not infected, the taking of a culture 
from its cavity may possibly be the means of introduc- 
ing infectious material; so we should not run even 
that slight risk till we have proved that the fever is not 
due to simple constipation. Similarly we should be 
sure there is no retention of urine. 

A word about the method of taking a culture. 
Both the patient's vulva and the physician's hands must 
be cleaned as thoroughly as for an operation. No 
bichloride or other antiseptic is to be used inside the 
vagina, for fear of inhibiting the growth of our culture. 
A bivalve speculum is carefully introduced, and the 
cervix exposed. The os is mopped off with sterile cot- 
ton pledgets, and the culture swab or culture tube in- 
troduced, taking care that it touches nothing till it 
meets the cervix. The best method for taking cul- 
tures from the uterine cavity is that described by 
Whitridge Williams. He employs a glass tube, threaded 
with a cord, to which a bunch of rubber bands is tied. 
These are drawn into the tube, where they should 
fit tightly, and form a piston. These bands are cut 
off flush with the end of the tube. When the end 
of the tube carrying the bands is introduced into the 
uterine cavity, traction on the cord coming out of 
the other end draws the rubber bands through 



ENDOMETRITIS. 265 

the tube, sucking into the glass whatever lochia is 
present. By closing the ends of the tube with seal- 
ing-wax, the fluid is carried uncontaminated to the 
laboratory, where the glass it broken in the middle, 
and a culture made in the usual manner from its 
contents. 

After the first chill and hyperpyrexia, the disease 
continues with daily rises and falls of temperature. 
There is frequently a morning drop of temperature to 
almost or quite normal, but there is always the evening 
rise, the highest temperature being noted between 4 
and 8 p. m. In severe cases there may be two maxima 
a day. The character of the curve may throw some 
light upon the micro-organism concerned. Colon and 
the putrefactive bacteria give a most marked morning 
recession of the fever. When the gonococcus is the 
offender, it is not unusual to find a subnormal morning 
temperature. A most striking example of this occurred 
in a patient whose temperature went from 108.7° F. to 
96.8° F. in six hours : she recovered. Gonococci were 
found in her culture in large numbers. In strepto- 
coccic infections, on the other hand, the temperature 
curve is more " platform " in character, and though 
there are morning recessions, the normal is rarely 
touched or even closely approached. As the condition 
advances, a metritis, salpingitis, pelvic phlebitis, or 
localized or general peritonitis is apt to supervene. 
The endometrial tissue may desquamate in large masses. 
This condition continues, with the up-and-down tem- 
perature, for days or weeks. If the outcome is fortu- 
nate, the fever gradually subsides; but the chronic 



266 ASEPTIC SURGICAL TECHNIQUE. 

endometritis, with frequently an associated salpingitis, 
may persist for years. Cases have been known in 
which a curetting, done under a rigid technique, ten 
years after an attack of streptococcic endometritis, has 
led to a recurrence of the trouble. 

It was formerly believed that streptococcic infections 
following labor were almost always fatal. Careful 
routine cultures of all febrile puerperia prove this is 
not the case, as has been shown in Whitridge Williams' 
clinic. A majority of all patients showing a tempera- 
ture above 100.5° in the puerperium have thus been 
shown to have a streptococcic infection, but the mor- 
tality among such cases is very small. It may be said, 
indeed, that in streptococcus cases, if the infection is 
of so low a virulence as to spread slowly enough for 
the development of a true endometritis, the prognosis 
for life is good. In the fatal cases the poison sweeps 
far beyond the endometrium in the first few hours. 
With the less virulent forms, as in colon infections and 
the like, the prognosis is usually good. 

It must be borne in mind that gonococci lying dor- 
mant in the generative tract can start up just such a 
trouble as we have described. Such cases are often the 
cause of the "one-child sterility" and are usually less 
severe than forms due to the pyogenic organisms. 
However, we have seen a woman die of general gono- 
coccal septicaemia, in whom at autopsy the gonococcus 
was found in every serous cavity, as well as in the 
uterus and on the heart valves. Such cases are due to 
no fault in technique of the attending surgeon or 
obstetrician ; but before one can shift the burden of 



ENDOMETRITIS. 267 

blame, one must prove bacteriologically the gonococcal 
nature of the infection. 

Numerous forms of treatment have been advocated 
for this septic endometritis. The patient should be 
kept as quiet as possible, and fed on liquids. If the 
stomach refuses to retain nourishment, nutrient ene- 
mata should be used about every four hours (see p. 
180). Sponge baths may be employed to combat 
hyperpyrexia, and strychnine, infusions, and other 
stimulants as the heart action indicates. 

If there is any suspicion that there is necrotic pla- 
cental tissue retained in the uterus, this must be 
removed. The cervix is always soft and patulous in 
such cases, but it may not admit a finger. After a 
thorough cleaning up of the patient and surgeon, the 
os is very gently dilated till a finger can be introduced. 
All retained tissue is then freed from the uterine wall, 
and removed with the finger, or with placental forceps. 
The soft condition of the uterine wall renders the 
employment of a curette very dangerous, and its use 
should be avoided. The uterus is then thoroughly 
irrigated, first, with peroxide of hydrogen (1 to 5), and 
then with saline solution. The cavity may then be 
packed with strips of iodoform gauze, which should be 
removed after 48 hours. If there is no indication of 
retained tissue, we may content ourselves with irriga- 
tions of the uterine cavity once or twice daily. For 
this procedure patient and doctor are cleaned up as for 
an operation. The os is exposed with a bivalve specu. 
lum, and the two-way irrigator carried gently up into 
the uterus. About one litre of saturated boric acid 



268 ASEPTIC SURGICAL TECHNIQUE. 

solution, at a temperature of 112°-115° F.,is used, fol- 
lowed by an equal amount of normal saline solution. The 
use of strong antiseptics in the uterine cavity, such as 
bichloride of mercury or carbolic acid (2-4 per-cent.), 
is advocated by many, and at times seems effective. 

The bowels must be very carefully watched. It is 
well to give a saline daily, or some castor oil. If the 
sepsis is marked, it is well to avoid the use of large 
purgative enemata. The distention of the lower bowel 
with such injections at times appears to have some 
causative influence upon the occurrence of a dreaded 
complication — pelvic phlebitis and thrombosis. 

Of late years, much work has been done with 
Wright's vaccines, and the use of immunizing sera in 
these cases. We have used vaccines repeatedly, both 
those grown from the patient's own organisms, obtained 
from free uterine or blood cultures, and also those from 
" stock" cultures ; but we cannot say that we have seen 
any definite good follow. The results from the use of 
serum from horses immunized to streptococci have been 
at times encouraging. Hirst, of Philadelphia (CI. Med. 
Jr., vol. ix, ~No. 5, p. 403), reports good results. He 
advocates very large doses, as much as 80 cc. in 24 
hours. In about 40 per-cent. of a small series of cases 
we have seen good results follow its use in doses of 20 
cc. per day. Whether these results were due to the 
serum, or to the intra-uterine douches employed during 
the same period, we are not prepared to say. At all 
events, no unfavorable results were noted, except a 
transient urticaria occasionally seen a week or ten days 
after the injections. 



ENDOMETRITIS. 269 

The pathological changes in such acute septic condi- 
tions of the endometrium are those of acute inflamma- 
tion, with marked necrosis. At times but little can be 
made out except some dilated vessels and nests of poly- 
morphonuclear leucocytes along the lymphatics. These 
are usually the most severe cases. In other forms, 
especially those due to putrefactive organisms, great 
masses of exfoliated necrotic tissue are observed upon 
an acutely inflamed base. Organisms may at times 
be stained in the tissues. 

A form of acute endometritis which is really only a 
variety of the kind we have been discussing is the so- 
called acute decidual endometritis. This form usually 
follows the incomplete abortions, generally induced by 
the woman herself or some one who has not employed 
clean hands or instruments. The infecting organisms, 
the clinical course of the disease, and the treatment, are 
the same as in the forms following labor or operation. 
The chief difference is that on examination of the 
uterine contents in these cases, the decidual tissue forms 
a striking feature of the picture. 

In all these forms complications must be carefully 
watched for. We must be ready to evacuate any 
accumulations of pus in the cul-de-sac or the broad 
ligaments ; and if peritonitis supervenes, we must not 
be caught off our guard. 

One other form of bacterial infection of the endo- 
metrium is due to B. tuberculosis. This may be either 
acute or chronic. Such a lesion is almost always 
secondary to tuberculosis of the tubes and ovaries, and 
gives rise to but few symptoms unless it be advanced 



270 ASEPTIC SURGICAL TECHNIQUE. 

sufficiently to involve the myometrium. Apparently 
this condition is more common in some clinics than in 
others. For example, it is reported much more often 
from Dr. Kelly's clinic at Johns Hopkins than from 
that of Lakeside Hospital, where it has been found 
three times in the microscopic examination of the last 
700 consecutive curettings. The pathological picture 
may vary greatly. Often more or less numerous mili- 
ary tubercles, with central caseation, giant-cells, and a 
leucocytic zone, may be found scattered throughout the 
endometrium. In other cases large caseous areas may be 
present. Still another form presents good-sized ulcer- 
ations, often extending into the myometrium. This 
condition may be cured by a thorough curetting, with 
removal of the involved adnexa. At times, the condi- 
tion grows steadily worse, involving all the coats of the 
uterus, and finally becoming jnerely a feature of a 
generalized tuberculosis. (Plate XXIY.) 

A true chronic endometritis is in our opinion much 
rarer than the statistics of diagnoses would indicate. 
Such a condition is not often seen except when com- 
plicated by some lesion of the tubes and ovaries ; other- 
wise the uterus is so well drained an organ that it can 
take care of most infections. The symptoms of such 
a chronic inflammation are chiefly a marked leucor- 
rhoea, combined with the pain or other symptoms be- 
longing to the complicating pyosalpinx or other lesion. 
The only treatment is a thorough curetting, together 
with the removal of the tubal or ovarian lesion. 

Microscopically, the endometrium shows a decrease 
in the cellular elements, with an increase in the inter- 



PLATE XXIV 




Tuberculous endometritis. (After Kelly.) 



ENDOMETRITIS. 271 

glandular connective tissue stroma. Numerous round- 
cells are found, and the gland-spaces, though not 
numerous, are filled with pus cells and desquamated 
epithelium. 

We now come to the second of our two main divi- 
sions of diseases of the endometrium. We have con- 
sidered infectious lesions ; let us now consider trophic 
changes. 

Vast numbers of names have been proposed to 
correspond to the vast numbers of pathological pictures 
found in these cases. But as each curetting really 
differs from every other one, there must be a limit 
somewhere to our nomenclature ; and the best way is 
to keep in mind a few well-marked groups, and as far 
as possible assign various cases to these groups. 

The glandular type is found in the matron ; the type 
associated with malpositions of the uterus, subinvolu- 
tion, fibroids, myomata, adherent adnexa, and the like. 
The actual pain suffered by these patients is more 
marked than that found in cases of the interstitial type, 
if we except the menstrual pains of the latter class. 
The discomfort is chiefly in the form of severe back- 
ache and " bearing down" pains. In this class, too, we 
may have some dysmenorrhoea, with abdominal and 
pelvic pains at the times of the periods. There is 
menorrhagia, leucorrhoea, and a long train of digestive 
and nervous symptoms, with sterility. 

The treatment is a thorough curettage, combined 
with correction of the associated malposition, and 
removal of any tumor that may be causing trouble. 

In the pathological picture, two distinct forms are 



272 ASEPTIC SURGICAL TECHNIQUE. 

seen. The glands may be increased in numbers — a 
hyperplasia ; or they may be increased in size and com- 
plexity — a hypertrophy. The two are often combined 
in varying proportions; but while a hypertrophy is 
common without a hyperplasia, the converse is Kot 
seen. The glands often become extremely complex, 
cork-screw-like, and dilated. The epithelial cells are 
increased in numbers ; and as they push out sideways, 
they force the entire tubule to twist and bend upon it- 
self, while at the same time the cells may " buckle up " 
into the lumen in small buds. The glands may then 
invade the myometrium more deeply than normally. 
Such a condition must be differentiated from decidual 
formation, where there is also a marked hypertrophy 
of the glands. True decidual cells can, however, 
usually be found in case there has been a pregnancy. 
The condition may also at times strongly suggest an 
adenocarcinoma, and the elimination of that possibility 
is often difficult or even impossible. In simple hyper- 
trophy, the cells are often enlarged, but they are regular 
in outline, with few mitotic figures. At times they 
appear to be in double layers, but if a thin section be 
examined this appearance will be found due to the fact 
that, as a result of the crowding, alternate cells carry 
their nuclei close to the base, while the others carry 
theirs high. The little " buds " also present only a 
single layer of cells. There is, moreover, no tendency 
to invasion. The more or less normal appearance of 
the individual epithelial cells, with absence of strange 
and bizarre forms, is the best indication of non-malig- 
nancy. The question, however, is very difficult at 



ENDOMETRITIS. 273 

times, and calls for a considerable amount of experience. 
Often the gland-spaces are distended, and at times 
actually cystic. (Plate XXIII., Fig. 2.) 

In hyperplastic forms, the glands should be evenly 
spaced, but more numerous than usual. The increase 
in spaces may be so great that the stroma represents a 
mere reticulum between the glands, and the tissue may 
be almost as sponge-like as a piece of lung parenchyma. 

In both these glandular forms, there is a marked 
gross thickening of the endometrium, which, as a 
result of the increase in the epithelial cells, may per- 
fectly well present the picture of the so-called " endo- 
metritis fungosa," a much abused term, which may 
include any form of endometritis which produces a 
marked thickening of the lining. Thus an endome- 
tritis of the " glandular-interstitial," " hyperplastic," 
" cystic," " hemorrhagic," or " exudative interstitial- 
glandular " type may perfectly well be termed " fun- 
gosa." 

By contrast with the glandular type, interstitial 
endometritis is usually a disease of young girls. It 
is found especially in cases of under-development of 
the uterus, generally associated with an acute ante- 
flexion and cervical stenosis. The most prominent 
symptom is dysmenorrhea, the pain before the flow 
and during the first days of the scanty period being 
often so severe as to confine the victim to bed. Here, 
too, we find occasionally a menorrhagia, but a lessened 
flow is the rule. There is often a leucorrhoea, com- 
bined with backache, especially at the menstrual 
periods. A thin, watery discharge is not infrequent. 



274 ASEPTIC SURGICAL TECHNIQUE. 

Here, too, we may find some digestive and nervous 
symptoms. There is often marked constipation, alter- 
nating with diarrhoea. Severe headaches are frequent, 
and there is often marked mental depression. Here, 
too, we find the cause of many cases of sterility in 
young married women, the mentally over-stimulated 
and physically under-developed product of modern 
" strenuosity." 

We need hardly he surprised at this when we look 
at the endometrium in such cases and think what poor 
soil it must afford for the implantation of a fertilized 
ovum. The changes may be divided into three groups, 
depending upon the length of time the condition has 
existed, the exudative interstitial endometritis, the 
cellular, and the sclerotic endometritis. In the exuda- 
tive type, the normal stroma cells are greatly enlarged, 
and may approximate a decidual type. All the stroma 
is permeated with exudate, so that the cells, although 
increased in number, are held widely apart. The 
glands maybe normal in number, but are separated 
so widely by the increase of interglandular tissue that 
they appear scanty. They are also much flattened, 
owing to the pressure exerted upon them. Theblood- 
and lymph-spaces are numerous. This form passes 
over into a chronic thinning and atrophy of the endo- 
metrium more readily than any other form. 

The cellular type is one in which there is but little 
exudate between the cells. These stroma cells, though 
much increased in numbers, are not so greatly hyper- 
trophied as in the other class of cases. Where three 
or four stroma cells normally lie between two adjacent 



ENDOMETRITIS. 275 

gland spaces, we may here find from eight to twelve or 
more. 

Both the above conditions lead to a great thickening 
of the endometrium, which may become 0.5 cm. or 
even more in depth. At times large shreds of this 
hypertrophied tissue may be desquamated and passed 
when engorged at a menstrual period, and even a per- 
fect cast of the uterine cavity may occasionally be seen. 
These cases are classed as instances of membranous dys- 
menorrhea. 

When of long standing, sclerotic changes appear 
in these interstitial forms. The superabundant stroma 
cells become less conspicuous, being largely replaced 
by connective-tissue cells, which go on to the forma- 
tion of true scar tissue. More and more fibrous 
elements thus appear, and the membrane becomes thin- 
ner as its blood supply decreases. Often the remain- 
ing gland-spaces are caught in the contracting scar. 
Their lumina being more or less blocked, the terminal 
portions fill with secretion, forming cystic spaces; or 
working out along the muscle layer they form long lob- 
ules running parallel to the surface of the endometrium. 

The logical treatment of this condition is a thorough 
stretching of the cervical canal, to afford good drain- 
age. The curette is then used thoroughly, and the 
complicating anteflexion is corrected by a stem or 
Wylie pessary. This must be worn for ten days. 
Good results often follow a gentle dilatation of the cer- 
vix with a small Goodell-Ellinger dilator during the 
convalescence. So little force is used in this treatment 
that ansesthesia is not necessary. 



276 ' ASEPTIC SURGICAL TECHNiqUE. 

After the operation in any of these cases, the patient 
should go in for a course of general hygienic treatment. 
Hydrastis, cannabis indica, iron, strychnine, and arsenic 
may all be used with advantage ; we often fail to treat 
properly the anaemia which is an important feature of 
many of these cases. 

The so-called senile endometritis is really a final stage 
in what we have spoken of as sclerotic interstitial 
endometritis. As the name implies, this is a disease of 
old age following the menopause. We frequently find 
a profuse milky discharge, which may erode the cervix 
and vaginal wall. The whole picture suggests a squa- 
mous cervical carcinoma, but the findings do not bear 
out this idea. At times the cervix becomes occluded, 
leading to the formation of a pyometrium. There is 
much distress and burning from the discharge, and there 
may be symptoms of septic absorption. Of course there 
is a secondary infection in these cases, which might seem 
to take them out of our class of trophic disturbances. 
However, the condition has originated in one of 
changed metabolism. The endometrium in these cases 
is very thin, often consisting only of a few rows of cells, 
with much scar tissue, and a few small glands. 

An interesting form, which is again really a variation 
of our interstitial type, is the polypoid endometritis. 
By this we do not mean the cases presenting a mucous 
cervical polyp, or a pedunculated submucous myoma, 
but rather a true general diffuse polypoid condition of 
the endometrium. This condition, too, occurs chiefly 
in young persons. The most prominent symptom is 
hemorrhage, generally a menorrhagia, but often a con- 



ENDOMETRITIS. 277 

Btant metrorrhagia is seen, and at times a patient will 
bleed constantly over a period of months. Sometimes, 
too, there will be a sudden hemorrhage, and we see 
cases in which this is so severe as to lead to a diagnosis 
of miscarriage. So great a loss of blood may lead to 
the gravest anaemia. The patients often present a 
ghastly waxy greenish pallor, and some of the lowest 
haemoglobin estimations are seen with this disease — 
30 per-cent. and even 20 per-cent. in severe cases. 
Naturally, there is great weakness, and the patients are 
prone to intercurrent infections of all kinds. 

The pathological picture shows a greatly increased 
stroma, so hypertrophied as to be piled up in the char- 
acteristic polypi. All the surface is covered with fairly 
normal epithelium, though the glands may be hyper- 
trophied. The blood-spaces are "large and numerous, 
and much extravasated blood may be present. The 
bleeding may be so severe as to require packing the uter- 
ine cavity. A thorough curetting will generally relieve 
the condition completely. At times, however, the bleed- 
ing recurs when the new endometrium has grown, and 
cases|are seen in which removal of the uterus is the only 
method of permanently stopping thefearful loss of blood. 

A reference to some pathological conditions of the uterine 
lining as altered by pregnancy may not be out of place. 
There are numerous diseases of the decidua which have 
been described, but about which comparatively little 
is known. The principal symptom of all 6uch lesions 
is abortion, which is inevitable, and which usually 
comes on early in the pregnancy. Preceding the abor- 
tion, these forms give rise to feelings of weight and 



278 ASEPTIC SURGICAL TECHNIQUE. 

distress in the lower abdomen; and there is frequently 
a brownish or bloody discharge. Such conditions are 
not amenable to treatment during the pregnancy ; but 
a thorough curetting after its termination, followed by 
hygienic measures, frequently leads to a cure. 

According to the classification of Whitridge Wil- 
liams, three groups of these cases may be mentioned. 
First, there may be a diffuse thickening of the entire 
endometrium, due to a general hypertrophy of the decid- 
ual elements, glandular and interstitial. Such a condition 
frequently leads to difficult separation of the placenta. 

A second group shows localized hypertrophic areas. 
Irregular, knob-like masses project from the inne'r sur- 
face of the uterus, and may become large and polypoid. 

The third group of decidual changes involves chiefly 
the glands in a marked hyperplasia. Here we find the 
gland-spaces persisting even after the time when the 
decidua reflexa and the vera normally unite, and these 
glands continue to pour out a watery fluid that drib- 
bles away in large quantities. At times, however, this 
fluid escapes in gushes, even as much as 500 c.c. at a 
time. This condition is termed hydrorrhea gravidarum, 
and is often mistaken for a rupture of the membranes. 

As to the technique of the operation of dilating the 
cervix and curetting the uterus : The vulva of the 
patient is carefully prepared as described in Chapter 
IV. Usually, however, it is unnecessary to shave the 
vulva if a simple curetting is all that is to be done. 
The surgeon and all his assistants clean up with the 
rigid technique that should always be observed. The 
index finger of the left hand locates the anterior lip of 



ENDOMETRITIS. 279 

the cervix, which is seized with a bullet forceps. The 
os is then exposed with the posterior blade of a Simon 
speculum. A sound is introduced into the cervix to 
determine the length and the direction of the canal. 
Then, in succession, Hagar's dilators, about sizes 13, 17, 
and 19, are introduced. The dilatation is then carried 
on with the small, medium, and finally the large sizes 
of the Goodell-Ellinger dilators. No screw or ratchet 
should be used on these instruments, and they should 
be separated in all directions, firmly but gently, great 
care being taken not to lacerate the cervix. About as 
much force should be exerted on the handles as is 
employed in a rather firm hand-shake. If there is an 
infection or a pregnancy very little force can be used. If 
no acute septic condition is present, we take the sharp 
Sims curette, and clean the cavity firmly and thor- 
oughly, going around in a circle so as to omit no area. 
After that, we use the modified Martin curette, which re- 
moves tissue from the fundus. The cavity is thoroughly 
irrigated with sterile normal saline solution. No uterine 
packing is required, but a gauze sponge may be placed 
in the vagina. This should be removed in 24 hours, 

"Where a marked septic condition is present, with pos- 
sibly retained placental tissue, a curette should not be 
used, except possibly in certain cases, and by a very 
skilled man. The uterine wall in such conditions is 
about as tough as wet paper, and is just as easy to per- 
forate. The results of perforation at such times are 
often serious. The finger, the placenta forceps, and 
the irrigating nozzle may be used with some safety, and 
give as good results as more radical curetting. 



INDEX. 



A. 

PAGE 

Abdomen, sterilization of 61, 62 

Abdominal bandage 191 

Abdominal cavity, closure of 173 

Abdominal section, care of patient after 178 

dressing after 173 

getting up after 190 

instruments for 71 

preparation of patient for 59-63 

Acid, boric 131, 134, 146 

Acid, carbolic 40, 82, 130 

in hypodermic solutions 142 

Acid, oxalic 44, 56 

Alcohol in skin disinfection 61, 62 

Anaesthesia in diagnosis 209 

methods of examination under 214-216 

preparation of patient for 213 

results of examinations under 211 

vomiting after 178, 180, 182 

Antisepsis 30 

Antiseptic gauzes 105-110 

powders , 134-135 

solutions 40-44 

Assistants, duties of 168 

number of 168 

training of . 46 

Autopsies, examinations at 222, 251 

importance of thorough 28, 222, 251 

281 



282 INDEX. 

B. pagb 

Bacillus aerogenes capsulatus 27 

coli communis 24, 25, 144 

pyocyaneus 25 

tetani 26 

tuberculosis 26 

Bacteria in laparotomy wounds 19 

Bacteria, pyogenic 16, 17 

Bacteriological examinations 218 

apparatus for 218 

at autopsies 222, 251 

diagnosis from 221 

for control of technique 221 

methods of making 219 

Bacteriology, relation of, to surgery 10 

Bacterium coli commune 24, 25, 144 

Bandage, abdominal 190 

Scultetus Ill 

Bichloride of mercury (see Corrosive sublimate). 

Bladder, catheterization of 144-145 

examination of 228 

irrigation of . . 5 146 

irritable 235 

Bladder-washing 146 

Blood, examination of 225 

"Blue pus" 26 

Boiling water for sterilization 35 

Boric acid powder 134 

solutions 131, 146 

C. 

Carbolic acid 40, 142 

solutions, poisoning from 82, 130 

Carriers 92 

Catgut 92, 99 

sterilization of 99-103 

unreliability of 99 



INDEX. 283 

PAGE 

Catheter, glass 145 

cleansing of 146 

sterilization of 145 

rubber 146 

Catheterization 144 

cystitis after 144, 189 

ureteral 229, 237 

Cautery, use of, in hemorrhage 173 

Celloidin, bichloride 137 

iodoformized 138 

Cervix, disisfection of 162 

instruments for dilating 77 

Clinical examinations 223 

of blood 225 

of cyst-contents 249 

of sputum t 226 

of urine 224 

Constipation after operations 186 

Corrosive sublimate, disinfecting power of 41 

Geppert's experiments with 41 

other experiments with 43 

solutions of 41 

addition of salt to 44 

toxicity of 42 

Cyst-contents, examination of 249 

Cystitis 144, 189, 235 

bacteria concerned in 144 

D. 

Dilators 78 

Disinfectants, chemical 40-44 

Disinfection of skin 52-56, 61, 62 

Drainage, capillary 119 

disadvantages of . 116 

gauze for 124 

rules for 124 



284 INDEX. 

PAGE 

Drainage-tubes, cleansing of 121 

dangers of 116 

forceps for „ 121 

glass 118 

removal of 122-124 

rubber 125 

Dressings, after abdominal sections 173, 175 

after plastic operations 193 

dry 107 

earth 104 

materials for 105, 137, 174 

removal of 174 

sterilization of . 106 

Dry heat for sterilization 34 

advantages of 35 

disadvantages of . . 35 

B. 

Earth-dressing, dangers of 104 

Endometritis, diagnosis of, from scrapings 244 

Enemata, for thirst 182 

laxative 187 

nutritive 180, 181 

simple 186 

Ether in skin disinfection 61, 62 

Examinations, bacteriological 218, 221, 222, 251 

clinical 223-227 

gynaecological , 209-217 

pathological 238 

F. 

Faeces, examination of 227 

Finger-nails, care of 61 

Fire, sterilization by 34, 82 

Formalin 44 



INDEX. 285 

G. PAGE 

Gauze, antiseptic . . . . , 105-110 

for sponges 112 

iodoforniized 109 

permanganate 110 

preservation of sterilized 108 

sterilization of 106 

subiodide of bismuth 110 

Germicides 30 

Glass catheters 145 

sterilization of 145 

Glass dishes, cleansing of 87 

sterilization of 87 

Glass drainage-tubes 118 

Gloves, rubber, care of 127 

sterilization of 126 

uses of 57, 125 

Gonococcus 23 

Gonorrhoea as a cause of pelvic abscess 23 

Gynaecological examinations 209-217 

anaesthesia for 209 

position of patient in 214 

preparation of patient for 213 

H. 

Hemorrhage, cautery in 173 

from separated adhesions 172 

intra-peritoneal 194 

Hot cans, use of, in shock 179 

Hypodermic injections, aseptic = 141 

dangers of 140 

sources of infection in 141 

Hypodermic solutions 142 

sterilization of 142 

Hypodermic syringes 143 

sterilization of 143 

17 



286 INDEX. 

I. PAGE 

Infection, causes of 13, 16 

general 15 

local 15 

Instrument-case 155 

Instruments, aluminium 67 

bags for 198 

canton-flannel sheets for 198 

chemical agents for sterilizing 82 

choice of 66 

cleansing of 88 

lists of gynaecological 68-80 

metal boxes for . 81, 90 

nickel-plating for 67 

Schimmelbusch's method of sterilizing 83 

sterilization of 80-84 

tables for 154, 201 

Instrument-trays 86-88 

sterilization of 87 

Iodoform powder * 134 

Iodoformized celloidin 138 

gauze 109 

oil 136 

Irrigating, methods of 133, 207 

Irrigation 128 

advantages of, in plastic cases 133, 207 

carbolic acid solutions for 130 

disadvantages of 43, 129 

normal salt solution for 131, 177 

sterile water for 130, 177 

sublimate solutions for 130 

various solutions for 131 

L. 

Laxative enemata 187 

Laxatives after operations 186, 187 

before examinations 213 



INDEX. 287 

PAGB 

Laxatives before operations 59 

Ligatures (see Sutures). 

M. 

Micrococcus gonorrhoeae 23 

Micrococcus lanceolatus 23 

Moist heat for sterilization 35-39 

Morphine after operations 185 

Myocarditis from gonococcus 23 

N. 

Nephritis in general infection 64 

Normal salt solution 131 

O. 

Oil, iodoformized 136 

Operating-room 148 

infection in 158 

in general hospital . 149, 150 

in private hospital 157 

in private house 200 

visitors in 166 

water-supply of 155, 156 

Operating-suits 47 

sterilization of 48 

Operating-table 150, 201 

Halsted's 152 

Horn-Martin 164 

Kelly's 151 

preparation of 163 

Operation, aseptic, description of 161 

Operations, care after 178 

chilling after 179 

diet after 179-182 

diet before 60 

organization of . . 160 

pain after 184-185 

restlessness after . 184-185 



288 INDEX. 

PAGE 

Operations, shock after 183 

Operations, major, getting up after 190 

preparation of patient for 59-63 

minor, death after 64 

getting up after 191 

preparation of patient for 69, 64, 176 

Operations outside hospitals 196-208 

instruments for . . 79 

Ovariotomy, instruments for 68, 73 

Ovariotomy-pad 164, 166 

Oxalic acid 44, 56, 63 



P. 

Paracentesis 143 

Pathological examinations 238 

Perineorrhaphy, dressing after 193 

general infection after 64 

getting up after . . . 191 

instruments for ...... ■ 77 

Peritoneum, incision into 169 



toilette of 170 

Peritonitis 194 

organisms concerned in 25 

vomiting in 183 

Permanganate gauze 110 

solution, for skin disinfection 56, 63 

Plastic operations, dressings after 193 

irrigation during 133, 207 

preparation of patient for 59, 64, 176 

Pneumococcus 24 

Potassium permanganate 44, 56, 63, 110 

Puncture, exploratory 143 

Pyaemia 15 

Pyosalpinx, sterility of pus in ..... 117 



INDEX. 289 

R» PAGE 

Razor, aseptic 62 

Rectum, cleansing of 65 

examination by 216 

Rubber dam 124 

sterilization of 125 

Rubber gloves, care of 127 

sterilization of 126 

uses of 57, 125 

Rubber tubing 125 

S. 

Salol as a substitute for iodoform 136 

Salt solution 131 

in skin disinfection 56 

Sapraemia 16 

Scrapings, uterine, examination of 243 

Sepsis 15 

Septicaemia 15 

Septico-pyaemia 15 

Shock, treatment of 184 

Silkworm-gut 97 

sterilization of 95 

Silver wire 98 

sterilization of 99 

Simon's speculum 77 

Sims's speculum 74 

Skin disinfection 62-54, 61, 62 

alcohol in 61, 62 

corrosive sublimate in 61 

ether in 61, 62 

Furbringer's method of 53 

mechanical 53, 54 

oxalic acid in 56, 63 

permanganate of potassium in 66, 63 

salt solution in 56, 63 

scrubbing in 64, 61 



290 INDEX. 

PAGE 

Soda solution, boiler for 85, 86 

disinfection with 84 

Solutions for instruments 87 

Spigot, attachment for 65 

Sponges, gauze 112 

Sponges, marine 112 

resterilization of . 114 

sterilization of .... 113 

Sputum, examination of 226 

Staphylococcus epidermidis albus 19, 52 

pyogenes albus 18 

pyogenes aureus 17, 144 

pyogenes citreus . 20 

Steam for sterilization 36-39 

Sterilization, fractional 38 

general principles of 33 

mechanical 33 

Sterilizers 35-38 

Sterilizing agents 33 

boiling water . . . . ' 35 

dry heat 34 

fire 34, 80 

moist heat 35-39 

soda solution 84 

steam 36-39 

Stomach contents, examination of 226 

Streptococcus erysipelatosus 20 

Streptococcus pyogenes 20 

in cystitis 144 

in laparotomy wounds 19 

in puerperal infection 21 

in vaginal secretions 21 

Stretchers 156 

Subiodide of bismuth gauze 110 

powder 135 

Sulphurous acid in skin disinfection ••••••« 44 



INDEX. 291 

PAGE 

Sutures, arrangement of 93 

glass reels for 94 

ignition test-tubes for . „ 94 

manipulation of , 103 

materials for 91, 92 

removal of 174, 192 

sterilization of 95, 253 

subcutaneous . . 173, 175 

trays for 89 

Sweat, bacteria in ......... 61 

Syringes, hypodermic , . . 143 

sterilization of .... e 143 

T. 

Tables for basins . . . 154, 201 

Tampons, cotton , Ill 

lamb's wool 110 

Tapping 143 

Technique, bacteriological control of 10, 221 

inconsistencies in ... 11 

mechanical 31 

Tissues, examination of 239 

Towels, sterilized 108 

Toxaemia 16 

Trachelorrhaphy, dressing after 193 

getting up after . . 191 

instruments for 77 

Trendelenburg position 165 

Tympanites, causes of 193 

treatment of . . , 193 

U. 

Ureter, bougie in 235 

Ureter, catheterization of, in female 229 

in male 237 

Ureteral catheterization, instruments for 80, 229 



292 INDEX. 

PAGE 

Ureteral orifice, method of finding 233 

Ureteral searcher 234 

Ureters, tying of 235 

Urine, examination of 224 

Uterine scrapings, chorionic villi in 245 

examination of „ „ „ . 243 

V. 

Vagina, disinfection of 65 

Vaginal hysterectomy, instruments for 73 

Vomiting after anaesthesia 178, 180, 182 

in peritonitis 183 

W. 

Water, sterile, for irrigation , * . . 130, 177 

Water-supply in operating-room 156 

Wound, abdominal, dressing of 173, 192 

Halsted's method of dressing ....... 175 

Wound, perineal, dressing of 193 

Wounds, laparotomy, organisms in ..'..... 19 



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